Provider Demographics
NPI:1750667192
Name:THERESA THANH NGOC NGUYEN, MD, INC.
Entity Type:Organization
Organization Name:THERESA THANH NGOC NGUYEN, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THANH
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-775-8090
Mailing Address - Street 1:15576 BROOKHURST ST STE B
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-7586
Mailing Address - Country:US
Mailing Address - Phone:714-775-8090
Mailing Address - Fax:714-775-2998
Practice Address - Street 1:15576 BROOKHURST ST STE B
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7586
Practice Address - Country:US
Practice Address - Phone:714-775-8090
Practice Address - Fax:714-775-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA61129AMedicare PIN