Provider Demographics
NPI:1407077407
Name:NGUYEN, QUAN T (DO)
Entity Type:Individual
Prefix:
First Name:QUAN
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-820-4906
Mailing Address - Fax:817-820-4815
Practice Address - Street 1:1300 W TERRELL AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-820-4906
Practice Address - Fax:817-820-4815
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016636207R00000X
TXN9275207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315030503OtherSTATE PHARMACY LICENSE
TX281177003Medicaid
TX281177001Medicaid
MI5101016636OtherSTATE MEDICAL LICENSE
TX281177002Medicaid
TX281177003Medicaid
TXTXB127925Medicare PIN
MI5315030503OtherSTATE PHARMACY LICENSE