Provider Demographics
NPI:1720092315
Name:NGUYEN, DAT Q (MD)
Entity Type:Individual
Prefix:DR
First Name:DAT
Middle Name:Q
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12954 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4418
Mailing Address - Country:US
Mailing Address - Phone:310-679-0269
Mailing Address - Fax:310-679-1038
Practice Address - Street 1:12954 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-4418
Practice Address - Country:US
Practice Address - Phone:310-679-0269
Practice Address - Fax:310-679-1038
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G775410Medicaid
CAG77541Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00G775410Medicaid