Provider Demographics
NPI:1700872769
Name:NGUYEN, THACH N (MD)
Entity Type:Individual
Prefix:
First Name:THACH
Middle Name:N
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST 86TH PLACE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6258
Mailing Address - Country:US
Mailing Address - Phone:219-756-1400
Mailing Address - Fax:219-746-0876
Practice Address - Street 1:200 E 86TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6258
Practice Address - Country:US
Practice Address - Phone:219-756-1400
Practice Address - Fax:219-746-0876
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033686207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100350720Medicaid
IN192820 CMedicare ID - Type Unspecified
IN878190CMedicare PIN
IN221020GMedicare PIN
IN169950CMedicare PIN
IN100350720Medicaid