Healthcare Provider Details

I. General information

NPI: 1396351490
Provider Name (Legal Business Name): TAN KIM DUONG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 WASHINGTON RD STE 200
WESTMINSTER MD
21157-5780
US

IV. Provider business mailing address

2661 RIVA RD STE 1030
ANNAPOLIS MD
21401-7131
US

V. Phone/Fax

Practice location:
  • Phone: 410-876-3333
  • Fax: 410-840-9133
Mailing address:
  • Phone: 667-354-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2776
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: