MEDICARE: JONATHAN DUONG O.D., INC.

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	152WL0500X	Low Vision Rehabilitation Optometrist	11127T	CA
2	152WV0400X	Vision Therapy Optometrist	11127T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700823283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN DUONG O.D., INC.

Provider Business Mailing Address
First Line	:	303 BROADWAY ST
Second Line	:	SUITE 105
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1816
Country	:	US
Telephone Number	:	949-715-2499
Fax Number	:	949-715-2493

Provider Business Practice Location Address
First Line	:	303 BROADWAY ST
Second Line	:	SUITE 105
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1816
Country	:	US
Telephone Number	:	949-715-2499
Fax Number	:	949-715-2493

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JONATHAN DUONG
Credential	:	O.D.
Telephone Number	:	949-715-2499

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	01/20/2010

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