Provider Demographics
NPI:1124066931
Name:NGUYEN, LIEN THI KIM (OD)
Entity type:Individual
Prefix:DR
First Name:LIEN
Middle Name:THI KIM
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9668 ASHSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E KETTLEMAN LN
Practice Address - Street 2:SUITE #18
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5962
Practice Address - Country:US
Practice Address - Phone:209-333-2221
Practice Address - Fax:209-333-7771
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12471 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124711Medicare PIN
CAU97752Medicare UPIN