Provider Demographics
NPI:1912220450
Name:THE EYE DOCTOR OPTOMETRY
Entity Type:Organization
Organization Name:THE EYE DOCTOR OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:TUNG LE
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-545-0257
Mailing Address - Street 1:806 AVENIDA PICO STE H
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-5695
Mailing Address - Country:US
Mailing Address - Phone:949-545-0257
Mailing Address - Fax:949-498-8238
Practice Address - Street 1:806 AVENIDA PICO STE H
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-5695
Practice Address - Country:US
Practice Address - Phone:949-545-0257
Practice Address - Fax:949-498-8238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12845T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV06921 CAMedicare UPIN