Healthcare Provider Details

I. General information

NPI: 1154435048
Provider Name (Legal Business Name): PHUONG LE AI DUONG OPTOMETRIST (O.D.)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 HILLSDALE AVE
SAN JOSE CA
95124-3027
US

IV. Provider business mailing address

630 BLOSSOM HILL RD STE 20
SAN JOSE CA
95123-3056
US

V. Phone/Fax

Practice location:
  • Phone: 408-269-1267
  • Fax: 408-269-1265
Mailing address:
  • Phone: 408-300-0717
  • Fax: 888-604-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberCA 12716 T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: