Provider Demographics
NPI:1497896922
Name:NGUYEN, JASMINE PHUONG (OD)
Entity Type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:PHUONG
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 43RD STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-8537
Mailing Address - Country:US
Mailing Address - Phone:619-284-3937
Mailing Address - Fax:619-284-3938
Practice Address - Street 1:4029 43RD STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8537
Practice Address - Country:US
Practice Address - Phone:619-284-3937
Practice Address - Fax:619-284-3938
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11189 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111890Medicaid
CASD0111890Medicaid
CA7928833Medicare UPIN
CAU84432Medicare UPIN
CA7928833Medicare UPIN