Provider Demographics
NPI:1457801854
Name:PETER T PHAM OD, PLLC
Entity Type:Organization
Organization Name:PETER T PHAM OD, PLLC
Other - Org Name:DR. PETER T PHAM & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:571-248-6246
Mailing Address - Street 1:8300 SUDLEY RD
Mailing Address - Street 2:STE I-6
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3458
Mailing Address - Country:US
Mailing Address - Phone:703-257-7580
Mailing Address - Fax:703-257-1455
Practice Address - Street 1:14044 PROMENADE COMMONS STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-4072
Practice Address - Country:US
Practice Address - Phone:571-248-6246
Practice Address - Fax:571-248-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002204152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003155946OtherNPI