Provider Demographics
NPI:1487092813
Name:PHAN, JULIE (OD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13250 DON JULIAN RD
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2239
Mailing Address - Country:US
Mailing Address - Phone:626-382-9096
Mailing Address - Fax:
Practice Address - Street 1:1055 HARRIMAN PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4203
Practice Address - Country:US
Practice Address - Phone:626-382-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2016-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist