Provider Demographics
NPI:1841208352
Name:PHAN, HUAN NGOC
Entity Type:Individual
Prefix:MR
First Name:HUAN
Middle Name:NGOC
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:HUAN
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20269 STEVENS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2258
Mailing Address - Country:US
Mailing Address - Phone:408-296-0100
Mailing Address - Fax:408-296-1795
Practice Address - Street 1:20269 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2258
Practice Address - Country:US
Practice Address - Phone:408-296-0100
Practice Address - Fax:408-296-1795
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77619207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G776190Medicaid
CA4465280001Medicare NSC
CA00G776191Medicare PIN
CA00G776190Medicaid