Healthcare Provider Details

I. General information

NPI: 1366935678
Provider Name (Legal Business Name): CHERYL C DUONG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 E ELDER ST STE 102
FALLBROOK CA
92028-3082
US

IV. Provider business mailing address

521 E ELDER ST STE 102
FALLBROOK CA
92028-3082
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-5728
  • Fax:
Mailing address:
  • Phone: 760-728-5728
  • Fax: 337-234-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1908-844AT
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34070TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: