Healthcare Provider Details

I. General information

NPI: 1922003748
Provider Name (Legal Business Name): VAN ANH THI NGUYEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10264 SOUTHERN MARYLAND BLVD STE 101
DUNKIRK MD
20754-3037
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 443-964-8705
  • Fax: 443-964-8707
Mailing address:
  • Phone: 703-847-8899
  • Fax: 866-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000815
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001439
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1858
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: