Provider Demographics
NPI:1063826899
Name:NGUYEN, JOHNNY THANH SON (DO)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:THANH SON
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100254
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0254
Mailing Address - Country:US
Mailing Address - Phone:352-273-8610
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15404207L00000X
TXBP1-0050304207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100042900Medicaid