Provider Demographics
NPI:1972099307
Name:PHAN, DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:PHAN
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 1:4840 N SHERIDAN RD APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4048
Mailing Address - Country:US
Mailing Address - Phone:312-330-7005
Mailing Address - Fax:
Practice Address - Street 1:1753 E 95TH ST STE B-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-364-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011205152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist