Provider Demographics
NPI:1215599667
Name:NGUYEN, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 TOWN N COUNTRY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4525
Mailing Address - Country:US
Mailing Address - Phone:813-507-5092
Mailing Address - Fax:
Practice Address - Street 1:5566 THOMASTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8118
Practice Address - Country:US
Practice Address - Phone:478-476-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-07
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOCP5708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist