Provider Demographics
NPI:1760672315
Name:TONY D PHAM OD INC
Entity Type:Organization
Organization Name:TONY D PHAM OD INC
Other - Org Name:MIRA MESA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:DIEU
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:858-535-8282
Mailing Address - Street 1:6755 MIRA MESA BLVD
Mailing Address - Street 2:SUITE 141
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4392
Mailing Address - Country:US
Mailing Address - Phone:858-535-8282
Mailing Address - Fax:858-535-0537
Practice Address - Street 1:6755 MIRA MESA BLVD.
Practice Address - Street 2:SUITE 141
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4311
Practice Address - Country:US
Practice Address - Phone:916-483-6661
Practice Address - Fax:916-483-6664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760672315Medicaid
CABQ051AMedicare PIN