Provider Demographics
NPI:1912998949
Name:TRUONG, MAI TO (OD)
Entity type:Individual
Prefix:DR
First Name:MAI
Middle Name:TO
Last Name:TRUONG
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 1:1020 N STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-3362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2449 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2305
Practice Address - Country:US
Practice Address - Phone:323-728-7149
Practice Address - Fax:323-728-7140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11968T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0119680Medicaid
CAMT0910465OtherDEA
CAU98537Medicare ID - Type Unspecified
CASD0119680Medicaid