Healthcare Provider Details

I. General information

NPI: 1225491764
Provider Name (Legal Business Name): MICHAEL NGUYEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 N US HIGHWAY 89
FLAGSTAFF AZ
86004-2837
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2054
  • Fax:
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0061983
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A16094
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberDR.0061983
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number10311
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: