Provider Demographics
NPI:1104454164
Name:PHAN, CONG THANH (MD)
Entity type:Individual
Prefix:
First Name:CONG
Middle Name:THANH
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2020
Mailing Address - Fax:
Practice Address - Street 1:5303 HARRY HINES BLVD
Practice Address - Street 2:6TH FLOOR
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-645-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV0115207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology