Provider Demographics
NPI:1417338898
Name:NGUYEN, JIM (DO)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:
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 1:1335 CYPRESS ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3538
Mailing Address - Country:US
Mailing Address - Phone:909-542-2777
Mailing Address - Fax:
Practice Address - Street 1:1335 CYPRESS ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3538
Practice Address - Country:US
Practice Address - Phone:909-542-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16296207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty