Provider Demographics
NPI:1407079791
Name:NGUYEN, CHARLES PHONG (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PHONG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5720
Mailing Address - Country:US
Mailing Address - Phone:646-772-1566
Mailing Address - Fax:
Practice Address - Street 1:2390 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5720
Practice Address - Country:US
Practice Address - Phone:646-772-1566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008941111N00000X, 111NI0013X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02132236Medicaid
NYU74419Medicare UPIN
NY02132236Medicaid