Provider Demographics
NPI:1831619998
Name:PHAM, KEVIN CUONG (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CUONG
Last Name:PHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:CUONG
Other - Middle Name:HUY
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3620 PIERCE ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7563
Mailing Address - Country:US
Mailing Address - Phone:701-799-8063
Mailing Address - Fax:
Practice Address - Street 1:445 MINNESOTA ST STE 1500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2269
Practice Address - Country:US
Practice Address - Phone:773-588-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3514K152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3514Medicaid