=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316330780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDY NGUYEN, OD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2015
-----------------------------------------------------
Last Update Date | 03/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6247 JARVIS AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94560-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-494-8880
-----------------------------------------------------
Fax | 510-494-8882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6247 JARVIS AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94560-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-494-8880
-----------------------------------------------------
Fax | 510-494-8882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUDY T. NGUYEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 510-494-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 14043TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------