Provider Demographics
NPI:1639331614
Name:TONNU, KIEUTIEN PHAN (OD)
Entity Type:Individual
Prefix:
First Name:KIEUTIEN
Middle Name:PHAN
Last Name:TONNU
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 1:1101 E HOLT AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5800
Mailing Address - Country:US
Mailing Address - Phone:909-620-4546
Mailing Address - Fax:909-620-4546
Practice Address - Street 1:1101 E HOLT AVE
Practice Address - Street 2:SUITE D
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5800
Practice Address - Country:US
Practice Address - Phone:909-620-4546
Practice Address - Fax:909-620-4546
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10429T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104290Medicaid
CAWY158OtherGROUP MEDICARE #
CAWOP10429FMedicare PIN
CAWY158OtherGROUP MEDICARE #