Provider Demographics
NPI:1194876961
Name:VU, TINA THI (OD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:THI
Last Name:VU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:42625 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-9737
Mailing Address - Country:US
Mailing Address - Phone:760-347-2897
Mailing Address - Fax:760-775-7802
Practice Address - Street 1:42625 JACKSON ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-9737
Practice Address - Country:US
Practice Address - Phone:760-347-2897
Practice Address - Fax:760-775-7802
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88802Medicare UPIN
CAWOP11773Medicare ID - Type Unspecified