Provider Demographics
NPI:1811026339
Name:NGUYEN, TAN DUY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TAN
Middle Name:DUY
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 FARRELLY DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1619
Mailing Address - Country:US
Mailing Address - Phone:510-351-1411
Mailing Address - Fax:510-351-1412
Practice Address - Street 1:333 ESTUDILLO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4717
Practice Address - Country:US
Practice Address - Phone:510-351-1411
Practice Address - Fax:510-351-1412
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3377213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33770Medicaid
CA000E33770Medicaid
CAT11661Medicare UPIN