Provider Demographics
NPI:1619653078
Name:PHAM, JANNA NGUYEN
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:NGUYEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 BUTLER BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4101
Mailing Address - Country:US
Mailing Address - Phone:713-798-6100
Mailing Address - Fax:
Practice Address - Street 1:1977 BUTLER BLVD FL 2
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4101
Practice Address - Country:US
Practice Address - Phone:713-798-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10853OtherOPTOMETRY LICENSE