Provider Demographics
NPI:1770831976
Name:PHAM, MAI LAN (OD)
Entity Type:Individual
Prefix:
First Name:MAI LAN
Middle Name:
Last Name:PHAM
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 1:375 OAK VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-9668
Mailing Address - Country:US
Mailing Address - Phone:831-751-9917
Mailing Address - Fax:831-751-9842
Practice Address - Street 1:1375 N DAVIS RD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93907-1991
Practice Address - Country:US
Practice Address - Phone:831-751-9917
Practice Address - Fax:831-751-9842
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA14484152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy