Provider Demographics
NPI:1598713851
Name:NGUYEN, BAO NGOC (DO)
Entity Type:Individual
Prefix:DR
First Name:BAO
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 HAMAKER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2229
Mailing Address - Country:US
Mailing Address - Phone:571-405-6882
Mailing Address - Fax:571-405-6883
Practice Address - Street 1:3025 HAMAKER CT STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2229
Practice Address - Country:US
Practice Address - Phone:571-405-6882
Practice Address - Fax:571-405-6883
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201555207Q00000X
MDH0082752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010219124Medicaid
VA018748C77Medicare ID - Type Unspecified
VA010219124Medicaid