MEDICARE: DR. DIEMKHANH MARY DINHLUU 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	OPT100277PA	CA

General Provider Information

NPI Number	:	1851496095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIEMKHANH MARY DINHLUU O.D.

Provider Business Mailing Address
First Line	:	2111 VALLEJO DR
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-8618
Country	:	US
Telephone Number	:	714-422-9921
Fax Number	:	714-505-0079

Provider Business Practice Location Address
First Line	:	2414 S FAIRVIEW ST STE 103
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92704-5318
Country	:	US
Telephone Number	:	714-557-9492
Fax Number	:	714-557-2548

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	12/15/2021

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