Provider Demographics
NPI:1881665743
Name:PHAM, BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
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 1:619 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-1331
Mailing Address - Country:US
Mailing Address - Phone:562-366-0777
Mailing Address - Fax:562-366-8877
Practice Address - Street 1:619 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-1331
Practice Address - Country:US
Practice Address - Phone:562-366-0777
Practice Address - Fax:562-366-8877
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12346T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5928230001Medicare NSC
CAOP12346Medicare PIN
CAV05598Medicare UPIN