Provider Demographics
NPI:1922123561
Name:NGUYEN, THAO PHUONG (OD)
Entity Type:Individual
Prefix:DR
First Name:THAO
Middle Name:PHUONG
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 1:14322 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-4608
Mailing Address - Country:US
Mailing Address - Phone:714-839-9996
Mailing Address - Fax:
Practice Address - Street 1:14322 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4608
Practice Address - Country:US
Practice Address - Phone:714-839-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 10149 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101490Medicaid
CASD0101490Medicaid
CAOP10149Medicare ID - Type Unspecified