Provider Demographics
NPI:1164423240
Name:CERVANTES, SUSAN TRUONG (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TRUONG
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:THAO
Other - Middle Name:DIEU
Other - Last Name:TRUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1662 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-5231
Mailing Address - Country:US
Mailing Address - Phone:760-788-3622
Mailing Address - Fax:760-788-4781
Practice Address - Street 1:1662 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-5231
Practice Address - Country:US
Practice Address - Phone:760-788-3622
Practice Address - Fax:760-788-4781
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12923152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist