Provider Demographics
NPI:1265450266
Name:NGUYEN, MAI PHUONG THI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAI PHUONG
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16027 BROOKHURST ST # G110
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1551
Mailing Address - Country:US
Mailing Address - Phone:707-225-7031
Mailing Address - Fax:714-531-1006
Practice Address - Street 1:16027 BROOKHURST ST # I-110
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1551
Practice Address - Country:US
Practice Address - Phone:844-527-8620
Practice Address - Fax:844-342-5278
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61956207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A619560Medicaid
CA1265450266OtherNPI
CA00A619560Medicaid