Provider Demographics
NPI:1164913026
Name:VAN, MONG LINH THI (OD)
Entity Type:Individual
Prefix:MISS
First Name:MONG LINH
Middle Name:THI
Last Name:VAN
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 1:5389 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8765
Mailing Address - Country:US
Mailing Address - Phone:850-995-3232
Mailing Address - Fax:850-995-2606
Practice Address - Street 1:5389 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8765
Practice Address - Country:US
Practice Address - Phone:850-995-3232
Practice Address - Fax:850-995-2606
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5507152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist