Provider Demographics
NPI:1962579912
Name:NGUYEN, PHUONG LAN MIMI (OD)
Entity type:Individual
Prefix:DR
First Name:PHUONG LAN
Middle Name:MIMI
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 1:215 LANCASTER AVE
Mailing Address - Street 2:F5
Mailing Address - City:FRAZER
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1874
Mailing Address - Country:US
Mailing Address - Phone:484-318-7851
Mailing Address - Fax:
Practice Address - Street 1:215 LANCASTER AVE
Practice Address - Street 2:F5
Practice Address - City:FRAZER
Practice Address - State:PA
Practice Address - Zip Code:19355-1874
Practice Address - Country:US
Practice Address - Phone:484-318-7851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00569200152W00000X
PAOEG001324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81364Medicare UPIN
042404Medicare ID - Type Unspecified