Provider Demographics
NPI:1871968453
Name:PHAN, THUY-LOAN
Entity type:Individual
Prefix:
First Name:THUY-LOAN
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:14700 BALTIMORE AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4877
Practice Address - Country:US
Practice Address - Phone:301-245-3903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDA2502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist