Provider Demographics
NPI:1912543109
Name:KIMBERLY NGUYEN DPM PC
Entity Type:Organization
Organization Name:KIMBERLY NGUYEN DPM PC
Other - Org Name:PHILLY CITY FOOT DOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:HOANG
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-726-1638
Mailing Address - Street 1:1311 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1867
Mailing Address - Country:US
Mailing Address - Phone:817-726-1638
Mailing Address - Fax:
Practice Address - Street 1:1311 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1867
Practice Address - Country:US
Practice Address - Phone:215-471-0433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033277130001Medicaid