Provider Demographics
NPI:1912494873
Name:NGUYEN, THACH BAO JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THACH BAO JONATHAN
Middle Name:
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 1:380 SUMMIT AVENUE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7807
Practice Address - Street 1:107 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3733
Practice Address - Country:US
Practice Address - Phone:740-266-2930
Practice Address - Fax:740-266-2931
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30293208000000X
OH35.141244208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0446768Medicaid