Healthcare Provider Details

I. General information

NPI: 1033782396
Provider Name (Legal Business Name): NHA-HAN NGUYEN-DEO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23119 SOBOBA RD
SAN JACINTO CA
92583-2903
US

IV. Provider business mailing address

23119 SOBOBA RD
SAN JACINTO CA
92583-2903
US

V. Phone/Fax

Practice location:
  • Phone: 909-654-0803
  • Fax:
Mailing address:
  • Phone: 951-654-0803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT35102TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT35102TLG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT35102TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: