Provider Demographics
NPI:1144588161
Name:NGUYEN, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
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 1:11871 BRAY ST
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6007
Mailing Address - Country:US
Mailing Address - Phone:310-980-3715
Mailing Address - Fax:
Practice Address - Street 1:29300 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630
Practice Address - Country:US
Practice Address - Phone:657-333-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1272812086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program