=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558661942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASMINE P. NGUYEN, O.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2010
-----------------------------------------------------
Last Update Date | 02/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4029 43RD STREET SUITE 300
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-8537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-284-3937
-----------------------------------------------------
Fax | 619-284-3938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4029 43RD STREET SUITE 300
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-8537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-284-3937
-----------------------------------------------------
Fax | 619-284-3938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JASMINE PHUONG NGUYEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 619-284-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 11189T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------