Provider Demographics
NPI:1346233954
Name:NGUYEN, SHANNON PHUONG (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name: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 1:12107 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3706
Mailing Address - Country:US
Mailing Address - Phone:714-373-5201
Mailing Address - Fax:714-373-5201
Practice Address - Street 1:12107 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3706
Practice Address - Country:US
Practice Address - Phone:714-373-5201
Practice Address - Fax:714-373-5201
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12487T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP12487Medicare PIN