Provider Demographics
NPI:1609369487
Name:NGUYEN, PHIVU (DO)
Entity Type:Individual
Prefix:
First Name:PHIVU
Middle Name:
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:RIVERSIDE MEDICAL CENTER
Mailing Address - Street 2:350 N WALL ST
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-928-6274
Mailing Address - Fax:
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2991
Practice Address - Country:US
Practice Address - Phone:815-928-6274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL036.157230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program