Provider Demographics
NPI:1063458503
Name:VAN DINH NGUYEN MEDICAL CORP.
Entity Type:Organization
Organization Name:VAN DINH NGUYEN MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAN
Authorized Official - Middle Name:DINH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-588-2186
Mailing Address - Street 1:7128 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4906
Mailing Address - Country:US
Mailing Address - Phone:323-588-2186
Mailing Address - Fax:323-588-0422
Practice Address - Street 1:7128 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4906
Practice Address - Country:US
Practice Address - Phone:323-588-2186
Practice Address - Fax:323-588-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64451207R00000X
CAA39092208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98130Medicare UPIN
CAE92247Medicare UPIN