Provider Demographics
NPI:1952604357
Name:ILES, VIVIAN YEN (OD)
Entity Type:Individual
Prefix:MISS
First Name:VIVIAN
Middle Name:YEN
Last Name:ILES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:YEN
Other - Last Name:DIEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:209-359-2045
Practice Address - Street 1:302 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3139
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:209-239-5295
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003002152W00000X
CAOPT15424-TLG152W00000X
390200000X
CA15424152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program