Provider Demographics
NPI:1396150587
Name:NGUYEN, THANH (OD)
Entity type:Individual
Prefix:DR
First Name:THANH
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1224
Mailing Address - Country:US
Mailing Address - Phone:727-895-2020
Mailing Address - Fax:727-823-8796
Practice Address - Street 1:1515 9TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1224
Practice Address - Country:US
Practice Address - Phone:727-895-2020
Practice Address - Fax:727-823-8796
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2426152W00000X
FLOPC5044152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15268300Medicaid