Provider Demographics
NPI:1538203294
Name:PHAM, ANTHONY TRUNG (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:TRUNG
Last Name:PHAM
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 1:2600 SW 136TH
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170
Mailing Address - Country:US
Mailing Address - Phone:405-455-2587
Mailing Address - Fax:405-733-3124
Practice Address - Street 1:3360 N AVE BLDG 685
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-9028
Practice Address - Country:US
Practice Address - Phone:405-455-2587
Practice Address - Fax:405-733-3124
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK700522101Medicare ID - Type Unspecified