Provider Demographics
NPI:1710900477
Name:PHAN, TUYET-MAI M (MD)
Entity Type:Individual
Prefix:DR
First Name:TUYET-MAI
Middle Name:M
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:T. MAI
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10681 BOLSA AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5270
Mailing Address - Country:US
Mailing Address - Phone:714-775-4400
Mailing Address - Fax:714-775-0149
Practice Address - Street 1:9500 BOLSA AVE
Practice Address - Street 2:STE P
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5943
Practice Address - Country:US
Practice Address - Phone:714-775-4400
Practice Address - Fax:714-775-0149
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57670207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G576702Medicaid
CA00G576702Medicaid
CAG57670AMedicare PIN
CAG57670BMedicare PIN