Provider Demographics
NPI:1457081424
Name:NGUYEN, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
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 1:262 GIBSON DR STE 130
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5885
Mailing Address - Country:US
Mailing Address - Phone:916-772-3937
Mailing Address - Fax:
Practice Address - Street 1:262 GIBSON DR STE 130
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5885
Practice Address - Country:US
Practice Address - Phone:916-772-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist