Provider Demographics
NPI:1124011952
Name:NGUYEN, HOANG (MD)
Entity Type:Individual
Prefix:
First Name:HOANG
Middle Name:
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 1:3930 BRIDLECREST AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-0200
Mailing Address - Country:US
Mailing Address - Phone:818-481-0118
Mailing Address - Fax:818-584-8926
Practice Address - Street 1:22135 ROSCOE BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3885
Practice Address - Country:US
Practice Address - Phone:818-481-0118
Practice Address - Fax:818-584-8926
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 60675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG 55700Medicare UPIN