Provider Demographics
NPI:1306921986
Name:NGUYEN, CHINH T (OD)
Entity type:Individual
Prefix:DR
First Name:CHINH
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 W MARCH LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5731
Mailing Address - Country:US
Mailing Address - Phone:209-952-4647
Mailing Address - Fax:209-952-4636
Practice Address - Street 1:87 W MARCH LN
Practice Address - Street 2:SUITE 2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5731
Practice Address - Country:US
Practice Address - Phone:209-952-4647
Practice Address - Fax:209-952-4636
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11714T152W00000X, 152WC0802X, 152WX0102X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11714TOtherCALIFORNIA LICENSE
CAP00737152OtherMEDICARE RAILROAD PTAN
CA1306921986Medicaid
CASD0117140Medicaid
CASD0117140Medicaid
CAMN1844528OtherDEA
CAP00737152OtherMEDICARE RAILROAD PTAN
CABE224Medicare UPIN