MEDICARE: NGAN KIM HUYNH LAM

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	OPC6062	FL

General Provider Information

NPI Number	:	1407423247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NGAN KIM HUYNH LAM

Provider Business Mailing Address
First Line	:	161 HAMPTON POINT DR STE 3
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-3058
Country	:	US
Telephone Number	:	904-287-9137
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 NOCATEE VILLAGE DR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5097
Country	:	US
Telephone Number	:	904-825-4525
Fax Number	:	904-825-4520

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

Provider Enumeration Date	:	06/09/2021
Last Update Date	:	11/18/2024

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