Provider Demographics
NPI:1619045929
Name:NGUYEN, BAO-KIM CAO (OD)
Entity Type:Individual
Prefix:
First Name:BAO-KIM
Middle Name:CAO
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 1:120 HOLMES STREET
Mailing Address - Street 2:#209
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171
Mailing Address - Country:US
Mailing Address - Phone:857-526-1299
Mailing Address - Fax:
Practice Address - Street 1:175 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2743
Practice Address - Country:US
Practice Address - Phone:617-523-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0705659Medicaid
V0650Medicare UPIN
MA0705659Medicaid