Provider Demographics
NPI:1649020702
Name:EYESMITH, A PROFESSIONAL OPTOMETRY CORPORATION
Entity type:Organization
Organization Name:EYESMITH, A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:THANH
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-600-1161
Mailing Address - Street 1:10956 PORTOBELO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-1181
Mailing Address - Country:US
Mailing Address - Phone:858-610-8488
Mailing Address - Fax:
Practice Address - Street 1:4029 43RD ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8537
Practice Address - Country:US
Practice Address - Phone:619-284-3937
Practice Address - Fax:619-284-3938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYESMITH, A PROFESSIONAL OPTOMETRY CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992813323Medicaid