Provider Demographics
NPI:1780093260
Name:PHAM, PETER VAN (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:VAN
Last Name:PHAM
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 1:2301 DAVE LYLE BLVD
Mailing Address - Street 2:SUITE 197
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-5289
Mailing Address - Country:US
Mailing Address - Phone:803-329-6464
Mailing Address - Fax:
Practice Address - Street 1:2301 DAVE LYLE BLVD
Practice Address - Street 2:SUITE 197
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5289
Practice Address - Country:US
Practice Address - Phone:803-329-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist