Provider Demographics
NPI:1386790244
Name:NGUYEN, KIMBERLY (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
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 1:3575 W WALNUT ST
Mailing Address - Street 2:C
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-6208
Mailing Address - Country:US
Mailing Address - Phone:972-272-9455
Mailing Address - Fax:
Practice Address - Street 1:3575 W WALNUT ST
Practice Address - Street 2:C
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6208
Practice Address - Country:US
Practice Address - Phone:972-272-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5741TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTX5741OtherEYEMED
TX11585OtherSPECTERA GROUP ID
TX918178OtherBLOCK MANAGED MEDICAID
TX041927701Medicaid
TX83271EMedicare PIN
TX918178OtherBLOCK MANAGED MEDICAID