Provider Demographics
NPI:1144302654
Name:TIEU, VINNIE (OD)
Entity type:Individual
Prefix:DR
First Name:VINNIE
Middle Name:
Last Name:TIEU
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 1:4275 E. CONCOURS DR. SUITE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4930
Mailing Address - Country:US
Mailing Address - Phone:909-476-7768
Mailing Address - Fax:909-476-7396
Practice Address - Street 1:4275 CONCOURS STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4932
Practice Address - Country:US
Practice Address - Phone:909-476-7768
Practice Address - Fax:909-476-7396
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11758TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117580Medicaid