Provider Demographics
NPI:1912562034
Name:PHAN, MICHELLE HOANG (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:HOANG
Last Name:PHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34-36 PROGRESS ST STE B4
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1197
Mailing Address - Country:US
Mailing Address - Phone:732-515-4405
Mailing Address - Fax:
Practice Address - Street 1:34-36 PROGRESS ST STE B4
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1197
Practice Address - Country:US
Practice Address - Phone:732-515-4405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ27OA00698500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program