Provider Demographics
NPI:1922003748
Name:NGUYEN, VAN ANH THI (OD)
Entity Type:Individual
Prefix:
First Name:VAN ANH
Middle Name:THI
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:STE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:10264 SOUTHERN MARYLAND BLVD STE 101
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3037
Practice Address - Country:US
Practice Address - Phone:443-964-8705
Practice Address - Fax:443-964-8707
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000815152W00000X
VA0618001439152W00000X
MDTA1858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU88679Medicare UPIN
PA054341Medicare ID - Type UnspecifiedINDIV PA MEDICARE NUMBER