Provider Demographics
NPI:1174778518
Name:MELODY TAM NGUYEN OD INC
Entity type:Organization
Organization Name:MELODY TAM NGUYEN OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:TAM
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-892-4171
Mailing Address - Street 1:9191 BOLSA AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5502
Mailing Address - Country:US
Mailing Address - Phone:714-892-4171
Mailing Address - Fax:714-891-3886
Practice Address - Street 1:9191 BOLSA AVE STE 116
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5502
Practice Address - Country:US
Practice Address - Phone:714-892-4171
Practice Address - Fax:714-891-3886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11086 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB853AOtherMEDICARE PTAN
CASD 0110861Medicaid
CAU76127Medicare UPIN
CACB206411Medicare PIN