Basic Information
| Provider Information | |||||||||
| NPI: | 1548723265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | LE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 NW 17TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052432020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 NW 17TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052432020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | OPC5650 | FL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT003314 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.