Provider Demographics
NPI:1093798423
Name:NGUYEN, PHONG H (MD)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:H
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BUENA VISTA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970
Mailing Address - Country:US
Mailing Address - Phone:434-447-3151
Mailing Address - Fax:434-774-2452
Practice Address - Street 1:125 BUENA VISTA CIRCLE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970
Practice Address - Country:US
Practice Address - Phone:434-447-3151
Practice Address - Fax:434-774-2452
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056241207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5869871Medicaid
VA5869871Medicaid
VA08000847Medicare ID - Type Unspecified