=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629630355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHIL PHONG NGUYEN OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2019
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1312 38TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11218-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-686-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4268 HUNTER ST FL 4
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11101-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | TUV008976
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | TUV008976
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV008976
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------