Provider Demographics
NPI:1518094317
Name:NGUYEN PHUC, BAO VINH (MD)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:VINH
Last Name:NGUYEN PHUC
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 1:1413 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-6614
Mailing Address - Country:US
Mailing Address - Phone:817-831-0034
Mailing Address - Fax:817-831-2030
Practice Address - Street 1:1413 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-6614
Practice Address - Country:US
Practice Address - Phone:817-831-0034
Practice Address - Fax:817-831-2030
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH97449Medicare UPIN