Healthcare Provider Details

I. General information

NPI: 1740495183
Provider Name (Legal Business Name): THI DONG BUU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25321 RAILROAD CANYON RD SUITE 503
LAKE ELSINORE CA
92532-2702
US

IV. Provider business mailing address

25321 RAILROAD CANYON ROAD SUITE 503
LAKE ELSINORE CA
92532-2702
US

V. Phone/Fax

Practice location:
  • Phone: 951-244-1122
  • Fax: 951-244-2777
Mailing address:
  • Phone: 951-244-1122
  • Fax: 951-244-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11411T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: