Basic Information
| Provider Information | |||||||||
| NPI: | 1003155946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | TIEN DZUNG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11936 JADE LAKE LN | ||||||||
| Address2: | |||||||||
| City: | BRISTOW | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201362231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503841554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8300 SUDLEY RD | ||||||||
| Address2: | STE I-6 | ||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201093458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503841554 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2013 | ||||||||
| LastUpdateDate: | 04/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618002204 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.