Provider Demographics
NPI:1255619953
Name:TRAN, PHONG QUOC (OD)
Entity type:Individual
Prefix:DR
First Name:PHONG
Middle Name:QUOC
Last Name:TRAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:20103 OLD SCENIC HWY STE 2B
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7386
Mailing Address - Country:US
Mailing Address - Phone:225-570-2753
Mailing Address - Fax:225-570-2758
Practice Address - Street 1:20103 OLD SCENIC HWY STE 2B
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791
Practice Address - Country:US
Practice Address - Phone:225-570-2753
Practice Address - Fax:225-570-2758
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1629-662T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2443381Medicaid