Provider Demographics
NPI:1740202746
Name:NGUYEN, HENRY (OD)
Entity type:Individual
Prefix:DR
First Name:HENRY
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 1:23080 ALESSANDRO BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9674
Mailing Address - Country:US
Mailing Address - Phone:951-656-3693
Mailing Address - Fax:951-656-3825
Practice Address - Street 1:23080 ALESSANDRO BLVD
Practice Address - Street 2:SUITE# 206
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9673
Practice Address - Country:US
Practice Address - Phone:951-656-3693
Practice Address - Fax:951-656-3825
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11717T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117171Medicaid
CAU95419Medicare UPIN
CASD0117171Medicaid