Provider Demographics
NPI:1861455412
Name:NGUYEN, TIEN HAC (MD)
Entity Type:Individual
Prefix:DR
First Name:TIEN
Middle Name:HAC
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 1:100 HIGHLANDS BLVD # 9
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2320
Mailing Address - Country:US
Mailing Address - Phone:631-473-1320
Mailing Address - Fax:
Practice Address - Street 1:210 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3522
Practice Address - Country:US
Practice Address - Phone:631-689-1400
Practice Address - Fax:631-689-1595
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206315-1207RI0011X, 207RC0000X
NY206315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02361842Medicaid
NY02361842Medicaid
NY458P11Medicare ID - Type Unspecified