Provider Demographics
NPI:1508414616
Name:TAM NGUYEN, O.D, PLLC
Entity Type:Organization
Organization Name:TAM NGUYEN, O.D, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-512-5004
Mailing Address - Street 1:3850 CONLON WAY STE F
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7665
Mailing Address - Country:US
Mailing Address - Phone:252-512-5004
Mailing Address - Fax:252-888-1442
Practice Address - Street 1:3850 CONLON WAY STE F
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7665
Practice Address - Country:US
Practice Address - Phone:252-512-5004
Practice Address - Fax:252-888-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618002584OtherOPTOMETRY LICENSE NUMBER