Provider Demographics
NPI:1629104930
Name:NGUYENPHUC, DIEMCHI (MD)
Entity Type:Individual
Prefix:
First Name:DIEMCHI
Middle Name:
Last Name:NGUYENPHUC
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 1:6572 POLO CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1542
Mailing Address - Country:US
Mailing Address - Phone:714-916-6453
Mailing Address - Fax:
Practice Address - Street 1:3501 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6919
Practice Address - Country:US
Practice Address - Phone:714-929-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68620207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G686200Medicaid
CA00G686200Medicaid
CAWG68620GMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE