Provider Demographics
NPI:1710972195
Name:NGUYEN, PHONG QUOC (OD)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:QUOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 S AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1512
Mailing Address - Country:US
Mailing Address - Phone:626-810-4535
Mailing Address - Fax:626-810-7371
Practice Address - Street 1:2402 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1512
Practice Address - Country:US
Practice Address - Phone:626-810-4535
Practice Address - Fax:626-810-7371
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11932T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6268104535OtherBLUE SHIELD OF CALIFORNIA
CAP041517OtherSPECTERA
CA204344OtherEYEMED
261324273OtherSUPERIOR VISION
CA261324273OtherMARCH VISION
CASD0119320Medicaid
CA202830204OtherNVA
CA204344OtherEYEMED
CAV08883Medicare UPIN
CABQ760ZMedicare PIN