Provider Demographics
NPI:1568475614
Name:NGUYEN, ETHAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
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 1:2067 W VISTA WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6033
Mailing Address - Country:US
Mailing Address - Phone:760-726-2180
Mailing Address - Fax:760-726-9928
Practice Address - Street 1:2067 W VISTA WAY STE 200
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6033
Practice Address - Country:US
Practice Address - Phone:760-726-2180
Practice Address - Fax:760-726-9928
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043290207R00000X
CAC167516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI34433Medicare UPIN