Provider Demographics
NPI:1811912868
Name:NGUYEN, KENNETH CQ (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CQ
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 1:14444 DALLAS PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8304
Mailing Address - Country:US
Mailing Address - Phone:972-385-6455
Mailing Address - Fax:
Practice Address - Street 1:14444 DALLAS PKWY
Practice Address - Street 2:STE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8304
Practice Address - Country:US
Practice Address - Phone:972-385-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A807510Medicaid
CA00A807510Medicaid