Provider Demographics
NPI:1013982024
Name:NGUYEN, TUNG THANH (DO)
Entity Type:Individual
Prefix:DR
First Name:TUNG
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 TULLY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-1013
Mailing Address - Country:US
Mailing Address - Phone:408-279-2988
Mailing Address - Fax:408-279-2981
Practice Address - Street 1:621 TULLY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1013
Practice Address - Country:US
Practice Address - Phone:408-279-2988
Practice Address - Fax:408-279-2981
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088650Medicaid
H67112Medicare UPIN
ZZZ19769ZMedicare ID - Type Unspecified