Provider Demographics
NPI:1851471023
Name:NGUYEN, CONNIE KHANH (MD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:KHANH
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 1:15355 BROOKHURST ST STE 102
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-7071
Mailing Address - Country:US
Mailing Address - Phone:714-775-3057
Mailing Address - Fax:714-531-1164
Practice Address - Street 1:15355 BROOKHURST ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7077
Practice Address - Country:US
Practice Address - Phone:714-775-3057
Practice Address - Fax:714-531-1164
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000A61492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A614920Medicaid
CAC82363Medicare UPIN