1679737712 NPI number — DR. TONY VAN PHAN O.D.

Table of content: (NPI 1508696576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679737712 NPI number — DR. TONY VAN PHAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAN
Provider First Name:
TONY
Provider Middle Name:
VAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679737712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1887 WHITNEY MESA DR # 4484
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89014-2069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-695-5550
Provider Business Mailing Address Fax Number:
972-417-9690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1927 E BELT LINE RD
Provider Second Line Business Practice Location Address:
SUITE 166
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75006-5821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-695-5550
Provider Business Practice Location Address Fax Number:
972-417-9690
Provider Enumeration Date:
07/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TX7275TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 216812201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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