Provider Demographics
NPI:1619011061
Name:NGUYEN, MAI PHAM (OD)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:PHAM
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 1:1174 AMHERST AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5883
Mailing Address - Country:US
Mailing Address - Phone:310-500-0853
Mailing Address - Fax:
Practice Address - Street 1:27420 TOURNEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5601
Practice Address - Country:US
Practice Address - Phone:661-259-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4511152W00000X
CA13235152W00000X
TX6559T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA42187OtherSPECTERA
MAMA0451OtherEYEMED