Provider Demographics
NPI:1033285689
Name:NGUYEN, LETHUY T (OD)
Entity Type:Individual
Prefix:DR
First Name:LETHUY
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:553 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5016
Mailing Address - Country:US
Mailing Address - Phone:909-985-2876
Mailing Address - Fax:909-946-8585
Practice Address - Street 1:553 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5016
Practice Address - Country:US
Practice Address - Phone:909-985-2876
Practice Address - Fax:909-946-8585
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099530Medicaid
CA37341Medicare UPIN
CAAU001YMedicare PIN
CASD0099530Medicaid