MEDICARE: DR. SHANNON PHUONG 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	12487T	CA

General Provider Information

NPI Number	:	1346233954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON PHUONG NGUYEN O.D.

Provider Business Mailing Address
First Line	:	12107 BEACH BLVD
Second Line	:
City	:	STANTON
State	:	CA
Zip	:	90680-3706
Country	:	US
Telephone Number	:	714-373-5201
Fax Number	:	714-373-5201

Provider Business Practice Location Address
First Line	:	12107 BEACH BLVD
Second Line	:
City	:	STANTON
State	:	CA
Zip	:	90680-3706
Country	:	US
Telephone Number	:	714-373-5201
Fax Number	:	714-373-5201

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	02/05/2013

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