Healthcare Provider Details

I. General information

NPI: 1356312375
Provider Name (Legal Business Name): MARK MINHDUY NGUYEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1
FPO AP
96350-1200
US

IV. Provider business mailing address

PSC 561 BOX 584
FPO AP
96310-0006
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-8658
  • Fax:
Mailing address:
  • Phone: 315-243-8658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2017-01752
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: