Provider Demographics
NPI:1811633217
Name:NGO, DIANA (OD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NGO
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 1:2600 POST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-3206
Mailing Address - Country:US
Mailing Address - Phone:203-255-4005
Mailing Address - Fax:
Practice Address - Street 1:2600 POST RD STE 210
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-3206
Practice Address - Country:US
Practice Address - Phone:203-255-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3223152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3223OtherCONNECTICUT LICENSE