Healthcare Provider Details

I. General information

NPI: 1730207168
Provider Name (Legal Business Name): KHANH HOANG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER PHUONG HOANG O.D.

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4893 LONE TREE WAY
ANTIOCH CA
94531-8553
US

IV. Provider business mailing address

2310 RIVERSIDE CT
SAN LEANDRO CA
94579-2796
US

V. Phone/Fax

Practice location:
  • Phone: 925-978-0296
  • Fax:
Mailing address:
  • Phone: 831-539-6836
  • Fax: 925-978-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11512T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: