Provider Demographics
NPI:1790044642
Name:NGUYEN, TO DUNG KHONG (MD)
Entity Type:Individual
Prefix:
First Name:TO DUNG
Middle Name:KHONG
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 1:11234 ANDERSON ST
Mailing Address - Street 2:GME OFFICE CSP 21005
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-4174
Mailing Address - Fax:
Practice Address - Street 1:2321 E UNDERHILL AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-3654
Practice Address - Country:US
Practice Address - Phone:714-402-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128196208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XMedicare UPIN