Provider Demographics
NPI:1174662886
Name:NGUYEN, LUCI THAO (MD)
Entity Type:Individual
Prefix:
First Name:LUCI
Middle Name:THAO
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LUCI
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:115 MEDICAL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3102
Mailing Address - Country:US
Mailing Address - Phone:361-578-7703
Mailing Address - Fax:
Practice Address - Street 1:115 MEDICAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3102
Practice Address - Country:US
Practice Address - Phone:361-578-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3358208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029727701Medicaid
TX8A5320Medicare PIN