MEDICARE: JIMMY NGUYEN O.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC 4478	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPC 4478	OTHER	FL	STATE LINCENSE

General Provider Information

NPI Number	:	1184944985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMY NGUYEN O.D

Provider Business Mailing Address
First Line	:	4417 CHESAPEAKE BAY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-4029
Country	:	US
Telephone Number	:	407-408-5177
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 W 7TH ST STE 145
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-9301
Country	:	US
Telephone Number	:	817-806-0265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2010
Last Update Date	:	07/13/2021

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