Provider Demographics
NPI:1134331549
Name:NGUYEN, TRUNG TAN (DO,MBA)
Entity Type:Individual
Prefix:
First Name:TRUNG
Middle Name:TAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:782 MEDICAL CENTER DR E # 212
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6889
Practice Address - Country:US
Practice Address - Phone:559-451-3676
Practice Address - Fax:559-451-3680
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10394207V00000X, 207VX0201X
NJMB08556700207V00000X
MO2005018242207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A10394OtherCA STATE LICENSE