Provider Demographics
NPI:1790152379
Name:NGUYEN, MARY NGOC-TRAM (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NGOC-TRAM
Last Name:NGUYEN
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 1:275 LIVE OAK LN
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-6759
Mailing Address - Country:US
Mailing Address - Phone:407-968-7749
Mailing Address - Fax:
Practice Address - Street 1:1260 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3969
Practice Address - Country:US
Practice Address - Phone:407-968-7749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003074152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist