Provider Demographics
NPI:1376593889
Name:NGUYEN, SON NGOC (MD)
Entity Type:Individual
Prefix:DR
First Name:SON
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES - 2ND FL
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2150 N WATERMAN AVE
Practice Address - Street 2:STE 202
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4811
Practice Address - Country:US
Practice Address - Phone:909-383-9385
Practice Address - Fax:909-882-2463
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ43246ZOtherBLUE SHIELD OF CA
CA1376593889Medicaid
CA1235318445Medicaid
CA00A491880Medicare ID - Type Unspecified
CAAZ518ZMedicare PIN
CAZZZ43246ZOtherBLUE SHIELD OF CA
CAZZZ43246ZMedicare PIN