Healthcare Provider Details

I. General information

NPI: 1316468176
Provider Name (Legal Business Name): MICHAEL DUONG, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 SAN RAMON VALLEY BLVD STE 101
SAN RAMON CA
94583-1661
US

IV. Provider business mailing address

2551 SAN RAMON VALLEY BLVD STE 101
SAN RAMON CA
94583-1661
US

V. Phone/Fax

Practice location:
  • Phone: 925-743-1222
  • Fax: 925-743-1221
Mailing address:
  • Phone: 925-743-1222
  • Fax: 925-743-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5287T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14540TLG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number14540TLG
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14540TLG
License Number StateCA

VIII. Authorized Official

Name: LYNDSY FAULKNER
Title or Position: ACCOUNTS MANAGER
Credential: CPOC
Phone: 925-743-1222