Healthcare Provider Details

I. General information

NPI: 1700823283
Provider Name (Legal Business Name): JONATHAN DUONG O.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 BROADWAY ST SUITE 105
LAGUNA BEACH CA
92651-1816
US

IV. Provider business mailing address

303 BROADWAY ST SUITE 105
LAGUNA BEACH CA
92651-1816
US

V. Phone/Fax

Practice location:
  • Phone: 949-715-2499
  • Fax: 949-715-2493
Mailing address:
  • Phone: 949-715-2499
  • Fax: 949-715-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number11127T
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number11127T
License Number StateCA

VIII. Authorized Official

Name: DR. JONATHAN DUONG
Title or Position: PRESIDENT
Credential: O.D.
Phone: 949-715-2499