Provider Demographics
NPI:1134475502
Name:NGUYEN, MONICA DIEM PHUONG (OD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:DIEM PHUONG
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 1:12 REVERE PL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3903
Mailing Address - Country:US
Mailing Address - Phone:225-284-6030
Mailing Address - Fax:
Practice Address - Street 1:1340 BOYLSTON ST # 6F
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4302
Practice Address - Country:US
Practice Address - Phone:617-927-6190
Practice Address - Fax:617-236-4262
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2309480Medicaid
LA2309480Medicaid