Provider Demographics
NPI:1871535617
Name:QUINTANA, MAI NGOC
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:NGOC
Last Name:QUINTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAI
Other - Middle Name:NGOC
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1007 S DANIEL WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3124
Mailing Address - Country:US
Mailing Address - Phone:408-569-9971
Mailing Address - Fax:
Practice Address - Street 1:419 N SHORELINE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4605
Practice Address - Country:US
Practice Address - Phone:650-967-5789
Practice Address - Fax:650-967-4106
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12693T152W00000X
CA12693TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0126930Medicare PIN
CAV03380Medicare UPIN