Provider Demographics
NPI:1285981274
Name:NGUYEN, MARY (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 CASTRO VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4402
Mailing Address - Country:US
Mailing Address - Phone:510-581-1680
Mailing Address - Fax:
Practice Address - Street 1:3550 CASTRO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4402
Practice Address - Country:US
Practice Address - Phone:510-581-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 14496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHD969ZMedicare PIN