Provider Demographics
NPI:1700823283
Name:JONATHAN DUONG O.D., INC.
Entity Type:Organization
Organization Name:JONATHAN DUONG O.D., INC.
Other - Org Name:LAGUNA COAST OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-715-2499
Mailing Address - Street 1:303 BROADWAY ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1816
Mailing Address - Country:US
Mailing Address - Phone:949-715-2499
Mailing Address - Fax:949-715-2493
Practice Address - Street 1:303 BROADWAY ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1816
Practice Address - Country:US
Practice Address - Phone:949-715-2499
Practice Address - Fax:949-715-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11127T152WL0500X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111270Medicaid
CASD0111270Medicaid