Basic Information
| Provider Information | |||||||||
| NPI: | 1972608008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | XUAN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19501 STEVENS CREEK BLVD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | CUPERTINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950142468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314241150 | ||||||||
| FaxNumber: | 8314241158 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 CONSTITUTION BLVD | ||||||||
| Address2: | BLDG. 400, STE. 100 | ||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939063100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314241150 | ||||||||
| FaxNumber: | 8314241158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT11435T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | SD0114350 | 05 | CA | MEDICAID |