Healthcare Provider Details

I. General information

NPI: 1215233598
Provider Name (Legal Business Name): SON TRANG NGUYEN OPTOMETRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 MOORPARK AVE SUITE 21
SAN JOSE CA
95117-1714
US

IV. Provider business mailing address

4155 MOORPARK AVE STE 21
SAN JOSE CA
95117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 408-243-2020
  • Fax: 408-243-2021
Mailing address:
  • Phone: 408-243-2020
  • Fax: 408-243-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14006
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number14006
License Number StateCA

VIII. Authorized Official

Name: SON TRANG NGUYEN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 408-309-8772