Healthcare Provider Details

I. General information

NPI: 1629630355
Provider Name (Legal Business Name): PHIL PHONG NGUYEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 38TH ST
BROOKLYN NY
11218-3612
US

IV. Provider business mailing address

4268 HUNTER ST FL 4
LONG ISLAND CITY NY
11101-4117
US

V. Phone/Fax

Practice location:
  • Phone: 718-686-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTUV008976
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTUV008976
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008976
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: