=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245733476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MY LINH TON-NU OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2018
-----------------------------------------------------
Last Update Date | 12/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 NEWPORT BLVD STE 220
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-3786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-951-3297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 SPRING HILL MALL
-----------------------------------------------------
City | WEST DUNDEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60118-1266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046011168
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT34990TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------