Provider Demographics
NPI:1750679171
Name:DUONG, JESSICA (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:DUONG
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 1:4294 RIVERWALK PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-8508
Mailing Address - Country:US
Mailing Address - Phone:909-225-7499
Mailing Address - Fax:
Practice Address - Street 1:4294 RIVERWALK PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-8508
Practice Address - Country:US
Practice Address - Phone:909-225-7499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14233TLG152W00000X, 152WP0200X, 152WS0006X, 152WX0102X
CA14233152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision