Provider Demographics
NPI:1417948449
Name:NGUYEN, QUANG (OD)
Entity Type:Individual
Prefix:
First Name:QUANG
Middle Name:
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 1:6945 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1754
Mailing Address - Country:US
Mailing Address - Phone:619-697-4600
Mailing Address - Fax:619-464-5526
Practice Address - Street 1:6945 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1754
Practice Address - Country:US
Practice Address - Phone:619-697-4600
Practice Address - Fax:619-464-5526
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT11814OtherSTATE LICENSE NUMBER
CAGR0052930Medicaid
CAGR0052930Medicaid