Healthcare Provider Details

I. General information

NPI: 1649406067
Provider Name (Legal Business Name): THERESA T NGUYEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-894-5775
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-894-5775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2617
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2010005351
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: