Provider Demographics
NPI:1427596352
Name:NGUYEN, VINH PHUC (OD60724663)
Entity Type:Individual
Prefix:
First Name:VINH
Middle Name:PHUC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD60724663
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 PIERCE CT NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3536
Mailing Address - Country:US
Mailing Address - Phone:206-412-5830
Mailing Address - Fax:
Practice Address - Street 1:762 OUTLET COLLECTION DR SW
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-6582
Practice Address - Country:US
Practice Address - Phone:253-804-3264
Practice Address - Fax:253-804-1065
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60724663152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2079522Medicaid