Provider Demographics
NPI:1902937741
Name:NGUYEN, TAI A (OD)
Entity Type:Individual
Prefix:DR
First Name:TAI
Middle Name:A
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1010
Mailing Address - Country:US
Mailing Address - Phone:860-956-1396
Mailing Address - Fax:860-956-8175
Practice Address - Street 1:90 ELM ST
Practice Address - Street 2:TARGET OPTICAL
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3770
Practice Address - Country:US
Practice Address - Phone:860-741-2020
Practice Address - Fax:860-956-8175
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU88992Medicare UPIN
CT410001104Medicare ID - Type Unspecified