Provider Demographics
NPI:1568460103
Name:NGUYEN, KENNETH VAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:VAN
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 1:448 E WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-4538
Mailing Address - Country:US
Mailing Address - Phone:215-324-2180
Mailing Address - Fax:215-324-2182
Practice Address - Street 1:448 E WYOMING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4538
Practice Address - Country:US
Practice Address - Phone:215-324-2180
Practice Address - Fax:215-324-2182
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 041413L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012074910001Medicaid
PA0012074910001Medicaid
PA0000614461Medicare ID - Type Unspecified