Provider Demographics
NPI:1942237193
Name:NGUYEN, LY THI (MD)
Entity Type:Individual
Prefix:
First Name:LY
Middle Name:THI
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 1:4691 OLD CANOE CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769
Mailing Address - Country:US
Mailing Address - Phone:407-891-2010
Mailing Address - Fax:407-891-8211
Practice Address - Street 1:4691 OLD CANOE CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769
Practice Address - Country:US
Practice Address - Phone:407-891-2010
Practice Address - Fax:407-891-8211
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 94908207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 94908OtherMEDICAL LICENSE NUMBER
FLBN9611446OtherDEA REGISTRATION NUMBER