Provider Demographics
NPI:1215233598
Name:SON TRANG NGUYEN OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:SON TRANG NGUYEN OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SON
Authorized Official - Middle Name:TRANG
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-309-8772
Mailing Address - Street 1:4155 MOORPARK AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1714
Mailing Address - Country:US
Mailing Address - Phone:408-243-2020
Mailing Address - Fax:408-243-2021
Practice Address - Street 1:4155 MOORPARK AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1714
Practice Address - Country:US
Practice Address - Phone:408-243-2020
Practice Address - Fax:408-243-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14006152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEZ277AMedicare PIN