Provider Demographics
NPI:1659798122
Name:NGUYEN, MY TIEN T (DO)
Entity Type:Individual
Prefix:
First Name:MY TIEN
Middle Name:T
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 1:1323 WYNDHAM LAKES DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6901 SIMMONS LOOP FL 4
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-9498
Practice Address - Country:US
Practice Address - Phone:813-302-8388
Practice Address - Fax:813-302-8453
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76874207Q00000X
390200000X
FLOS18292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program