Provider Demographics
NPI:1497193643
Name:NGUYEN, TIM THANH (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THANH
Other - Middle Name:TRONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1870 LUNDY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-1826
Mailing Address - Country:US
Mailing Address - Phone:408-573-9686
Mailing Address - Fax:
Practice Address - Street 1:1870 LUNDY AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1826
Practice Address - Country:US
Practice Address - Phone:408-573-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126136207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program