1700823283 NPI number — JONATHAN DUONG O.D., INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700823283 NPI number — JONATHAN DUONG O.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONATHAN DUONG O.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAGUNA COAST OPTOMETRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700823283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 BROADWAY ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-715-2499
Provider Business Mailing Address Fax Number:
949-715-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LAGUNA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92651-1816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-715-2499
Provider Business Practice Location Address Fax Number:
949-715-2493
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUONG
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-715-2499

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  11127T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 11127T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SD0111270 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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