Provider Demographics
NPI:1215021167
Name:LIEU S. NGUYEN, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIEU S. NGUYEN, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LIEU
Authorized Official - Middle Name:SANH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-675-7343
Mailing Address - Street 1:15032 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8316
Mailing Address - Country:US
Mailing Address - Phone:310-675-7343
Mailing Address - Fax:310-675-1951
Practice Address - Street 1:15032 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8316
Practice Address - Country:US
Practice Address - Phone:310-675-7343
Practice Address - Fax:310-675-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432170Medicaid
CAA43217Medicare ID - Type Unspecified
CA00A432170Medicaid