Provider Demographics
NPI:1346366093
Name:NGUYEN, TAM THU (OD)
Entity Type:Individual
Prefix:DR
First Name:TAM
Middle Name:THU
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:TAM
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12132 CANDOR DR
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6923
Mailing Address - Country:US
Mailing Address - Phone:714-235-3415
Mailing Address - Fax:
Practice Address - Street 1:9191 BOLSA AVE
Practice Address - Street 2:116
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5564
Practice Address - Country:US
Practice Address - Phone:714-235-3415
Practice Address - Fax:909-987-4956
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11086T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD 0110861Medicaid
CAU76127Medicare UPIN
CASD 0110861Medicaid