Provider Demographics
NPI:1710974951
Name:NGUYEN, BENJAMIN (MD)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
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 1:649 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2568
Mailing Address - Country:US
Mailing Address - Phone:248-584-5590
Mailing Address - Fax:248-584-5591
Practice Address - Street 1:649 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2568
Practice Address - Country:US
Practice Address - Phone:248-584-5590
Practice Address - Fax:248-584-5591
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4257639Medicaid
MI4257639Medicaid
MIH13133Medicare UPIN