Provider Demographics
NPI:1558324350
Name:NGUYEN, MINDY C (OD)
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:C
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 1:11809 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-6919
Mailing Address - Country:US
Mailing Address - Phone:847-515-2030
Mailing Address - Fax:847-515-2040
Practice Address - Street 1:11809 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-6919
Practice Address - Country:US
Practice Address - Phone:847-515-2030
Practice Address - Fax:847-515-2040
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6721TG152W00000X
IL046009841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009841Medicaid
V06749Medicare UPIN
ILK50580Medicare PIN
IL046009841Medicaid
ILK29170Medicare PIN
ILK29170Medicare PIN
TX1785636-01Medicaid