Provider Demographics
NPI:1134165194
Name:NGUYEN, THANH THE (DO)
Entity type:Individual
Prefix:DR
First Name:THANH
Middle Name:THE
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 1:1505 WILSON TER
Mailing Address - Street 2:SUITE 320
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4071
Mailing Address - Country:US
Mailing Address - Phone:818-243-3147
Mailing Address - Fax:818-244-7593
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE 320
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-243-3147
Practice Address - Fax:818-244-7593
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7029207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A7029Medicare ID - Type Unspecified
G50110Medicare UPIN