Provider Demographics
NPI:1073036943
Name:NGUYEN, TIFFANY TRINH (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:TRINH
Last Name:NGUYEN
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 1:200 BANNING ST STE 130
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3486
Mailing Address - Country:US
Mailing Address - Phone:302-450-3025
Mailing Address - Fax:302-678-2330
Practice Address - Street 1:200 BANNING ST STE 130
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3486
Practice Address - Country:US
Practice Address - Phone:302-678-1700
Practice Address - Fax:302-678-2330
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK123305152W00000X
DEI4-0000097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEI4-0000097OtherDELAWARE THERAPEUTIC OPTOMETRIST INTERN
AK123305OtherBOARD OF EXAMINERS OF ALASKA
DEI3-0001409OtherDELAWARE OPTOMETRIST