Provider Demographics
NPI:1457338154
Name:PHAM, HEIDI QT (O,D,)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:QT
Last Name:PHAM
Suffix:
Gender:F
Credentials:O,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8684 MARIALAINA CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-5063
Mailing Address - Country:US
Mailing Address - Phone:916-929-5909
Mailing Address - Fax:916-929-8202
Practice Address - Street 1:1869 ARDEN FAIR MALL,
Practice Address - Street 2:SUITE 1091
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815
Practice Address - Country:US
Practice Address - Phone:916-929-5909
Practice Address - Fax:916-929-8202
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11521T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD011521Medicaid
CAU81422Medicare UPIN
CASD011521Medicaid