Provider Demographics
NPI:1255746947
Name:PHAM, KIM NGAN THI (OD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:NGAN THI
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 1:2655 GULF TO BAY BLVD
Mailing Address - Street 2:PHAMILY EYE CARE OPTICAL
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-373-1954
Mailing Address - Fax:
Practice Address - Street 1:2655 GULF TO BAY BLVD
Practice Address - Street 2:PHAMILY EYE CARE OPTICAL
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759
Practice Address - Country:US
Practice Address - Phone:727-373-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-22
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12717067OtherCAQH
FLHV948ZMedicare PIN