Healthcare Provider Details

I. General information

NPI: 1962839670
Provider Name (Legal Business Name): ICONIC EYES OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 E BROKAW RD #50
SAN JOSE CA
95131-2318
US

IV. Provider business mailing address

1055 E BROKAW RD #50
SAN JOSE CA
95131-2318
US

V. Phone/Fax

Practice location:
  • Phone: 408-887-4993
  • Fax:
Mailing address:
  • Phone: 408-887-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14223
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code156FX1201X
TaxonomyOptometric Assistant Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTINE N NGO
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 408-887-4993