Provider Demographics
NPI:1679737712
Name:PHAN, TONY VAN (OD)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:VAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1887 WHITNEY MESA DR # 4484
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2069
Mailing Address - Country:US
Mailing Address - Phone:972-695-5550
Mailing Address - Fax:972-417-9690
Practice Address - Street 1:1927 E BELT LINE RD
Practice Address - Street 2:SUITE 166
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5821
Practice Address - Country:US
Practice Address - Phone:972-695-5550
Practice Address - Fax:972-417-9690
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX7275TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216812201Medicaid
TX216812201Medicaid