MEDICARE: NICOLE PHAM NGUYEN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	34968	CA

General Provider Information

NPI Number	:	1023787249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE PHAM NGUYEN OD

Provider Business Mailing Address
First Line	:	317 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	317 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3011
Country	:	US
Telephone Number	:	323-465-9682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2021
Last Update Date	:	04/06/2023

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