Healthcare Provider Details

I. General information

NPI: 1205621026
Provider Name (Legal Business Name): PHUONG NGUYET PHUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7379 INDIANA AVE
RIVERSIDE CA
92504-4547
US

IV. Provider business mailing address

7379 INDIANA AVE
RIVERSIDE CA
92504-4547
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-7822
  • Fax: 951-977-8075
Mailing address:
  • Phone: 916-661-9973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36282
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: