Provider Demographics
NPI:1104828508
Name:NGUYEN, ETHAN-QUAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN-QUAN
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 1:4336 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3518
Mailing Address - Country:US
Mailing Address - Phone:951-682-9293
Mailing Address - Fax:
Practice Address - Street 1:4336 MARKET ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3518
Practice Address - Country:US
Practice Address - Phone:951-682-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-08-01
Deactivation Date:2006-05-05
Deactivation Code:
Reactivation Date:2006-05-05
Provider Licenses
StateLicense IDTaxonomies
CAG77748207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA030454716OtherTAX ID
CAZZZ31422ZMedicare ID - Type Unspecified