Healthcare Provider Details

I. General information

NPI: 1477121713
Provider Name (Legal Business Name): TIEN JOHNNY BAO CAO-NGUYEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 N EL CAMINO REAL STE C202
ENCINITAS CA
92024-1332
US

IV. Provider business mailing address

10383 FERN AVE APT B
STANTON CA
90680-1772
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV009413-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT34988-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: