Provider Demographics
NPI:1700268448
Name:PHAN, JOHNNY (OD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7552 JULIET LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1096
Mailing Address - Country:US
Mailing Address - Phone:817-899-5989
Mailing Address - Fax:
Practice Address - Street 1:990 U.S. 287 FRONTAGE RD
Practice Address - Street 2:#109
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-453-4682
Practice Address - Fax:817-453-4353
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8720152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist