Provider Demographics
NPI:1104102201
Name:HA, YEN KIM NGUYEN (OD)
Entity type:Individual
Prefix:
First Name:YEN
Middle Name:KIM NGUYEN
Last Name:HA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:YEN
Other - Middle Name:KIM
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2021 MAYCREST AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4208
Mailing Address - Country:US
Mailing Address - Phone:626-731-2425
Mailing Address - Fax:
Practice Address - Street 1:3668 MOTOR AVE
Practice Address - Street 2:#310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5759
Practice Address - Country:US
Practice Address - Phone:626-731-2425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist