Provider Demographics
NPI:1326094533
Name:NGUYEN, JACKIE K (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:K
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 1:53 SEWALL STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-828-2020
Mailing Address - Fax:207-773-7034
Practice Address - Street 1:53 SEWALL STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-828-2020
Practice Address - Fax:207-773-7034
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017896207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433089999Medicaid
MEL40606Medicare UPIN
ME433089999Medicaid