Provider Demographics
NPI:1568408250
Name:NGUYEN, PHILLIP T (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:T
Last Name:NGUYEN
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:PO BOX 16076
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-6076
Mailing Address - Country:US
Mailing Address - Phone:601-982-6001
Mailing Address - Fax:601-982-8616
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-982-6001
Practice Address - Fax:601-982-8616
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14929207PE0004X
TN41357207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116449Medicaid
MS00116449Medicaid
MSG37000Medicare UPIN