Provider Demographics
NPI:1780319442
Name:NGUYEN, PHUONG THAO (MD)
Entity type:Individual
Prefix:
First Name:PHUONG THAO
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13192 BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1003
Mailing Address - Country:US
Mailing Address - Phone:989-980-4586
Mailing Address - Fax:
Practice Address - Street 1:939 STORY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-2688
Practice Address - Country:US
Practice Address - Phone:408-573-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA204487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine