Provider Demographics
NPI:1972889343
Name:PHAM, MARIA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:PHAM
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 1:1042 PATAPSCO ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4595
Mailing Address - Country:US
Mailing Address - Phone:800-485-9196
Mailing Address - Fax:
Practice Address - Street 1:1042 PATAPSCO ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4595
Practice Address - Country:US
Practice Address - Phone:800-485-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2284152W00000X
WV1094OD152W00000X
VA0618002092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA2284OtherOPTOMETRY TPA LICENSE
VA0618002092OtherOPTOMETRY TPA LICENSE