Provider Demographics
NPI:1275612319
Name:NGUYEN, MAI HOANG (MD)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:HOANG
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 1:410 MAPLE AVE W STE 3
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4224
Mailing Address - Country:US
Mailing Address - Phone:703-281-3626
Mailing Address - Fax:703-281-3615
Practice Address - Street 1:410 MAPLE AVE W STE 3
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4224
Practice Address - Country:US
Practice Address - Phone:703-281-3626
Practice Address - Fax:703-281-3615
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94851207Q00000X
VA0101244058207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA948510Medicaid