Provider Demographics
NPI:1245248103
Name:NGUYEN, TUNG VAN (DO)
Entity type:Individual
Prefix:
First Name:TUNG
Middle Name:VAN
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 1:1790 MULKEY RD
Mailing Address - Street 2:STE. 8
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1122
Mailing Address - Country:US
Mailing Address - Phone:770-944-1830
Mailing Address - Fax:770-739-0260
Practice Address - Street 1:657 VININGS ESTATES DR SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:404-274-5182
Practice Address - Fax:678-398-5442
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H26788Medicare UPIN
08BBRJGMedicare ID - Type Unspecified