Provider Demographics
NPI:1831851120
Name:INTHAVONG, VISAKA DIANNA (OD)
Entity type:Individual
Prefix:DR
First Name:VISAKA
Middle Name:DIANNA
Last Name:INTHAVONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANNA
Other - Middle Name:
Other - Last Name:INTHAVONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:305 POLLASKY AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1139
Mailing Address - Country:US
Mailing Address - Phone:559-298-2120
Mailing Address - Fax:
Practice Address - Street 1:305 POLLASKY AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1139
Practice Address - Country:US
Practice Address - Phone:559-298-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist