Provider Demographics
NPI:1710019443
Name:PHAN, KATHY L (OD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:PHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1520 SPRING HILL MALL
Mailing Address - Street 2:LENSCRAFTERS #408
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1266
Mailing Address - Country:US
Mailing Address - Phone:847-426-4624
Mailing Address - Fax:847-426-5334
Practice Address - Street 1:1520 SPRING HILL MALL
Practice Address - Street 2:LENSCRAFTERS #408
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-1266
Practice Address - Country:US
Practice Address - Phone:847-426-4624
Practice Address - Fax:847-426-5334
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist