Healthcare Provider Details

I. General information

NPI: 1093253247
Provider Name (Legal Business Name): MINH-TAM NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8424 OLD KEENE MILL RD
SPRINGFIELD VA
22152-2302
US

IV. Provider business mailing address

8424 OLD KEENE MILL RD
SPRINGFIELD VA
22152-2302
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-6611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003247
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002638
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2628
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: