Provider Demographics
NPI:1801235387
Name:PHAN, MONGNGHI THI (OD)
Entity type:Individual
Prefix:
First Name:MONGNGHI
Middle Name:THI
Last Name:PHAN
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 1:8024 SLIDE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5230
Mailing Address - Country:US
Mailing Address - Phone:817-896-5028
Mailing Address - Fax:
Practice Address - Street 1:8024 SLIDE ROCK RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-5230
Practice Address - Country:US
Practice Address - Phone:817-896-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8229T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist