Provider Demographics
NPI:1578523965
Name:NGUYEN-FAMULARE, NGOC M (MD)
Entity Type:Individual
Prefix:DR
First Name:NGOC
Middle Name:M
Last Name:NGUYEN-FAMULARE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WEATHERVANE WAY
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8128
Mailing Address - Country:US
Mailing Address - Phone:631-667-6455
Mailing Address - Fax:
Practice Address - Street 1:216 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3901
Practice Address - Country:US
Practice Address - Phone:516-741-0570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226208207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02675001Medicaid
NYI03548Medicare UPIN
NY02675001Medicaid