Provider Demographics
NPI:1962839670
Name:ICONIC EYES OPTOMETRY
Entity Type:Organization
Organization Name:ICONIC EYES OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-887-4993
Mailing Address - Street 1:1055 E BROKAW RD
Mailing Address - Street 2:#50
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2318
Mailing Address - Country:US
Mailing Address - Phone:408-887-4993
Mailing Address - Fax:
Practice Address - Street 1:1055 E BROKAW RD
Practice Address - Street 2:#50
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2318
Practice Address - Country:US
Practice Address - Phone:408-887-4993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14223152W00000X
156FX1201X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty