Healthcare Provider Details

I. General information

NPI: 1063570992
Provider Name (Legal Business Name): JENNIFER NGAI YEN TAM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7862 EL CAJON BLVD
LA MESA CA
91942-6712
US

IV. Provider business mailing address

7862 EL CAJON BLVD
LA MESA CA
91942-6712
US

V. Phone/Fax

Practice location:
  • Phone: 619-644-6405
  • Fax: 619-461-5158
Mailing address:
  • Phone: 619-644-6405
  • Fax: 619-644-6495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number12707T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: