Provider Demographics
NPI:1821124397
Name:NGUYEN, JIMMY TUNG LE (OD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:TUNG LE
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2183 VISTA WAY
Mailing Address - Street 2:STE B6
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5680
Mailing Address - Country:US
Mailing Address - Phone:714-210-3405
Mailing Address - Fax:714-839-7424
Practice Address - Street 1:2183 VISTA WAY
Practice Address - Street 2:STE B6
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5680
Practice Address - Country:US
Practice Address - Phone:714-210-3405
Practice Address - Fax:714-839-7424
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12845T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV06921Medicare UPIN