Healthcare Provider Details

I. General information

NPI: 1548634504
Provider Name (Legal Business Name): JESSICA DUONG,O.D.INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4294 RIVERWALK PKWY STE 204
RIVERSIDE CA
92505-3378
US

IV. Provider business mailing address

4294 RIVERWALK PKWY STE 204
RIVERSIDE CA
92505-3378
US

V. Phone/Fax

Practice location:
  • Phone: 909-225-7499
  • Fax:
Mailing address:
  • Phone: 909-225-7499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14233TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number14233TLG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number14233TLG
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number14233TLG
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number14233TLG
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number14233TLG
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14233TLG
License Number StateCA

VIII. Authorized Official

Name: JESSICA DUONG
Title or Position: CEO/OPTOMETRIST
Credential: O.D.
Phone: 909-225-7499