Provider Demographics
NPI:1629024880
Name:NGUYEN, AN (MD)
Entity Type:Individual
Prefix:
First Name:AN
Middle Name:
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 1:4130 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-3807
Mailing Address - Country:US
Mailing Address - Phone:616-281-0093
Mailing Address - Fax:616-281-0580
Practice Address - Street 1:4130 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-3807
Practice Address - Country:US
Practice Address - Phone:616-281-0093
Practice Address - Fax:616-281-0580
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415770Medicaid
MI4194172Medicaid
MI4878918Medicaid
MI4155595Medicaid
MI2995085Medicaid
MI4155595Medicaid
MI2995085Medicaid
MIM02830021Medicare ID - Type Unspecified
MI3415770Medicaid