Provider Demographics
NPI:1821086273
Name:PHAM, LOC (OD)
Entity Type:Individual
Prefix:DR
First Name:LOC
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:1275 E FLORENCE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-4268
Practice Address - Country:US
Practice Address - Phone:520-426-1600
Practice Address - Fax:520-426-1608
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ164133Medicare PIN
AZZ162077Medicare PIN
AZZ164134Medicare PIN
AZZ162078Medicare PIN
AZZ162075Medicare PIN
AZZ164136Medicare PIN
AZU98787Medicare UPIN
AZZ162074Medicare PIN
AZZ114375Medicare PIN
AZZ162079Medicare PIN
AZZ164131Medicare PIN
AZZ164132Medicare PIN
AZZ164135Medicare PIN
AZZ162076Medicare PIN