Provider Demographics
NPI:1013452234
Name:DR JULIE PHAN OD INC
Entity Type:Organization
Organization Name:DR JULIE PHAN OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-799-3130
Mailing Address - Street 1:13250 DON JULIAN RD
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2239
Mailing Address - Country:US
Mailing Address - Phone:626-382-9096
Mailing Address - Fax:
Practice Address - Street 1:1055 HARRIMAN PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4203
Practice Address - Country:US
Practice Address - Phone:909-799-3130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14612TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty