Provider Demographics
NPI:1679667364
Name:NGUYEN, KHANH TRUONG (MD)
Entity Type:Individual
Prefix:DR
First Name:KHANH
Middle Name:TRUONG
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:PO BOX 661297
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1297
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:409 N PACIFIC COAST HWY
Practice Address - Street 2:SUITE 928
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2870
Practice Address - Country:US
Practice Address - Phone:310-374-2145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96169207P00000X, 207R00000X
NY230691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A961690Medicaid
CA00A961690Medicaid
CAWA96169BMedicare PIN
CAWA96169CMedicare PIN