Provider Demographics
NPI:1821082421
Name:NGUYEN, KHOA DANG (MD)
Entity Type:Individual
Prefix:
First Name:KHOA
Middle Name:DANG
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:P.O. BOX 3578
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3578
Mailing Address - Country:US
Mailing Address - Phone:706-737-4575
Mailing Address - Fax:706-731-5289
Practice Address - Street 1:1499 FAIR ROAD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-486-1533
Practice Address - Fax:912-871-2396
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0537932085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0204X, 2085U0001X
GA537932085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00061112OtherRAILROAD MEDICARE
GA889490068AMedicaid
GA30017056OtherKEYSTONE MERCY
GA889490068CMedicaid
SCG53793Medicaid
GA002515OtherBLUE CROSS
GA889490068CMedicaid
GA30BDLGVMedicare PIN
GA002515OtherBLUE CROSS