Provider Demographics
NPI:1912092107
Name:NGUYEN, THAIDUC (DO)
Entity Type:Individual
Prefix:
First Name:THAIDUC
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 N COURTENAY PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4852
Mailing Address - Country:US
Mailing Address - Phone:321-784-8211
Mailing Address - Fax:321-394-8425
Practice Address - Street 1:595 N COURTENAY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4852
Practice Address - Country:US
Practice Address - Phone:321-784-8211
Practice Address - Fax:321-394-9425
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34 008818207L00000X
FLOS13604207L00000X, 207LP2900X
OH34008818207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2699003Medicaid
OH2699003Medicaid