Provider Demographics
NPI:1689628331
Name:NGUYEN, KIM NGA (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:NGA
Last Name:NGUYEN
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 1:2461 SANTA MONICA BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2138
Mailing Address - Country:US
Mailing Address - Phone:866-487-7621
Mailing Address - Fax:310-388-3029
Practice Address - Street 1:2461 SANTA MONICA BLVD
Practice Address - Street 2:STE 108
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2138
Practice Address - Country:US
Practice Address - Phone:866-487-7621
Practice Address - Fax:310-388-3029
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300269174400000X
PAMD4178832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020226630001Medicaid
OHKN4219572OtherMEDICARE PTAN
OH2793240Medicaid
OH2793240Medicaid
PA118641Medicare PIN