Provider Demographics
NPI:1588673024
Name:NGUYEN, BAO ANH LE (MD)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:ANH LE
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 1:1441 E VIA VERDE DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-8806
Mailing Address - Country:US
Mailing Address - Phone:559-478-7017
Mailing Address - Fax:559-433-0443
Practice Address - Street 1:1441 E VIA VERDE DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93730-8806
Practice Address - Country:US
Practice Address - Phone:559-478-7017
Practice Address - Fax:559-433-0443
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891260Medicaid
CA00A891260Medicare PIN
00A891261Medicare PIN