Provider Demographics
NPI:1780638726
Name:VU, TAN DUY (OD)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:DUY
Last Name:VU
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 1:34859 FREDRICK STREET
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7007
Mailing Address - Country:US
Mailing Address - Phone:951-678-7690
Mailing Address - Fax:951-837-4816
Practice Address - Street 1:34859 FREDRICK STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7007
Practice Address - Country:US
Practice Address - Phone:951-678-7690
Practice Address - Fax:951-837-4816
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12670T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0126700Medicaid
CA6143837OtherMEDICAID PIN
CA6143837OtherMEDICAID PIN
CASD0126700Medicaid