Healthcare Provider Details

I. General information

NPI: 1558324350
Provider Name (Legal Business Name): MINDY C NGUYEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11809 MAIN ST
HUNTLEY IL
60142-6919
US

IV. Provider business mailing address

11809 MAIN ST
HUNTLEY IL
60142-6919
US

V. Phone/Fax

Practice location:
  • Phone: 847-515-2030
  • Fax: 847-515-2040
Mailing address:
  • Phone: 847-515-2030
  • Fax: 847-515-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6721TG
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009841
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: