Provider Demographics
NPI:1568499630
Name:NGUYEN, LOC VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LOC
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 1:10362 BOLSA AVE
Mailing Address - Street 2:BOLSA MEDICAL GROUP
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6763
Mailing Address - Country:US
Mailing Address - Phone:714-531-2091
Mailing Address - Fax:714-531-1403
Practice Address - Street 1:10362 BOLSA AVE
Practice Address - Street 2:BOLSA MEDICAL GROUP
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6763
Practice Address - Country:US
Practice Address - Phone:714-531-2091
Practice Address - Fax:714-531-1403
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45406208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A454060Medicaid
CAWA45406BMedicare ID - Type Unspecified
CA00A454060Medicaid