Provider Demographics
NPI:1538366984
Name:PHAN, LAURA T (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:T
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20398 BLAUER DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-4307
Mailing Address - Country:US
Mailing Address - Phone:408-502-5000
Mailing Address - Fax:408-502-5505
Practice Address - Street 1:20398 BLAUER DR
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4307
Practice Address - Country:US
Practice Address - Phone:408-502-5000
Practice Address - Fax:408-502-5505
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126463207W00000X, 207WX0200X
MDD72821207W00000X
MI4301097337207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD047445200Medicaid
MD047445200Medicaid