Provider Demographics
NPI:1659413284
Name:PHAM, TIFFANY THUY (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:THUY
Last Name:PHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13192 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1740
Mailing Address - Country:US
Mailing Address - Phone:714-534-3100
Mailing Address - Fax:714-534-3108
Practice Address - Street 1:13192 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1740
Practice Address - Country:US
Practice Address - Phone:714-534-3100
Practice Address - Fax:714-534-3108
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10399T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103990Medicaid
CASD0103990Medicaid
CAU53996Medicare UPIN