Provider Demographics
NPI:1154435048
Name:DUONG, PHUONG LE AI (OPTOMETRIST (OD))
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:LE AI
Last Name:DUONG
Suffix:
Gender:F
Credentials:OPTOMETRIST (OD)
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:630 BLOSSOM HILL RD STE 20
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3056
Mailing Address - Country:US
Mailing Address - Phone:408-300-0717
Mailing Address - Fax:888-604-2519
Practice Address - Street 1:1811 HILLSDALE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3027
Practice Address - Country:US
Practice Address - Phone:408-269-1267
Practice Address - Fax:408-269-1265
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CACA 12716 T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12716OtherLICENSE NUMBER