Provider Demographics
NPI:1699766949
Name:PHAM, TAN-LONG (MS, OD)
Entity type:Individual
Prefix:DR
First Name:TAN-LONG
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:MS, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:316 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1710
Practice Address - Country:US
Practice Address - Phone:239-226-2640
Practice Address - Fax:239-458-0178
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4085152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621103800Medicaid
FLU7179WOtherMEDICARE
FLOPC 4085OtherFL LICENSE
FLOPC 4085OtherFL LICENSE
CAOP1719OtherEYEMED VISION CARE