Healthcare Provider Details

I. General information

NPI: 1417443185
Provider Name (Legal Business Name): IRIS C HUANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 B AVE OPTOMETRY CLINIC
ZUNI NM
87327
US

IV. Provider business mailing address

PO BOX 899
ZUNI NM
87327-0899
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-7485
  • Fax: 505-782-7489
Mailing address:
  • Phone: 510-213-8316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0003410
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: