Provider Demographics
NPI:1477646644
Name:NGUYEN, THY A (OD)
Entity type:Individual
Prefix:DR
First Name:THY
Middle Name:A
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 1:12731 NEW BRITTANY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3632
Mailing Address - Country:US
Mailing Address - Phone:239-418-0999
Mailing Address - Fax:239-418-0091
Practice Address - Street 1:12731 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3632
Practice Address - Country:US
Practice Address - Phone:239-418-0999
Practice Address - Fax:239-418-0091
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620580100Medicaid
FLOPC3567OtherOD LICENSE
FL36002OtherBLUE CROSS
FLP01541812OtherRAIL ROAD MEDICARE
FL620580100Medicaid
FLE5292OMedicare PIN