Provider Demographics
NPI:1205934858
Name:NGUYEN, THAO THANH (OD)
Entity type:Individual
Prefix:DR
First Name:THAO
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20910 FREDERICK RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4134
Mailing Address - Country:US
Mailing Address - Phone:301-515-6708
Mailing Address - Fax:301-515-6714
Practice Address - Street 1:20910 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4134
Practice Address - Country:US
Practice Address - Phone:301-515-6708
Practice Address - Fax:301-515-6714
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA 1698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU85671Medicare UPIN