Provider Demographics
NPI:1770239709
Name:ISHIDA, VANESSA QUYNH (OD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:QUYNH
Last Name:ISHIDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:QUYNH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:254 BALLENA DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1703
Mailing Address - Country:US
Mailing Address - Phone:714-548-0694
Mailing Address - Fax:
Practice Address - Street 1:16855 VALLEY BLVD STE A-B
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6621
Practice Address - Country:US
Practice Address - Phone:909-320-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35097152W00000X
CA35097TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist