Provider Demographics
NPI:1376685958
Name:NGUYEN, PETER HOA (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HOA
Last Name:NGUYEN
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 1:14506 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-3158
Mailing Address - Country:US
Mailing Address - Phone:310-324-3139
Mailing Address - Fax:310-324-7052
Practice Address - Street 1:14506 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3158
Practice Address - Country:US
Practice Address - Phone:310-324-3139
Practice Address - Fax:310-324-7052
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9919T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099190Medicaid
CASD0099190Medicaid