Provider Demographics
NPI:1740261585
Name:NGUYEN, PHITHAO J (DO FAAFP)
Entity type:Individual
Prefix:
First Name:PHITHAO
Middle Name:J
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DO FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4713
Mailing Address - Country:US
Mailing Address - Phone:847-696-3176
Mailing Address - Fax:
Practice Address - Street 1:711 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4713
Practice Address - Country:US
Practice Address - Phone:847-696-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110939207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I21373Medicare UPIN
K12499Medicare ID - Type Unspecified