Provider Demographics
NPI:1841214285
Name:NGUYEN, LIEU (MD)
Entity Type:Individual
Prefix:
First Name:LIEU
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 1:15032 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-675-7343
Mailing Address - Fax:310-675-1951
Practice Address - Street 1:15032 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-675-7343
Practice Address - Fax:310-675-1951
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432170Medicaid
CAF02638Medicare UPIN
CAA43217Medicare ID - Type Unspecified