Healthcare Provider Details

I. General information

NPI: 1013937747
Provider Name (Legal Business Name): SUMIN MARK HUANG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 N WATERMAN AVE SUITE 3
SAN BERNARDINO CA
92404-4842
US

IV. Provider business mailing address

1909 N WATERMAN AVE SUITE 3
SAN BERNARDINO CA
92404-4842
US

V. Phone/Fax

Practice location:
  • Phone: 909-882-8883
  • Fax: 909-882-8810
Mailing address:
  • Phone: 909-882-8883
  • Fax: 909-882-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7227T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: