Provider Demographics
NPI:1710085840
Name:NG, MIMI T (OD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:T
Last Name:NG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MONIKA
Other - Middle Name:
Other - Last Name:NG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 60422
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80960-0422
Mailing Address - Country:US
Mailing Address - Phone:714-478-6645
Mailing Address - Fax:719-266-1735
Practice Address - Street 1:4667 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3304
Practice Address - Country:US
Practice Address - Phone:719-590-1744
Practice Address - Fax:719-266-1735
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC810024Medicare PIN