Provider Demographics
NPI:1649378761
Name:NGUYEN, PHAN (DO)
Entity Type:Individual
Prefix:
First Name:PHAN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:16271 BASS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3616
Practice Address - Country:US
Practice Address - Phone:239-343-7100
Practice Address - Fax:239-343-7190
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12836207VX0000X
MI5101013356207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160B576250OtherBLUE CROSS BLUE SHIELD
MI114832810Medicaid
MI0M89170007Medicare ID - Type Unspecified
MI114832810Medicaid