Provider Demographics
NPI:1588790828
Name:PHAM, PHONG MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:PHONG
Middle Name:MICHAEL
Last Name:PHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:6747 WILLOW LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1253
Mailing Address - Country:US
Mailing Address - Phone:239-472-4204
Mailing Address - Fax:239-415-7341
Practice Address - Street 1:1571 PERIWINKLE WAY
Practice Address - Street 2:
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-4513
Practice Address - Country:US
Practice Address - Phone:239-472-4204
Practice Address - Fax:239-415-7341
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3502152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6097ZMedicare PIN
FLU87694Medicare UPIN