Provider Demographics
NPI:1366484115
Name:DUONG, JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:DUONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W TEMPLE ST
Mailing Address - Street 2:STE 7136
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-7336
Mailing Address - Country:US
Mailing Address - Phone:213-663-2150
Mailing Address - Fax:
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:STE 7136
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7336
Practice Address - Country:US
Practice Address - Phone:213-663-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11127T152WL0500X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111270Medicaid
CASD0111270Medicaid
CAWOP11127AMedicare PIN