Healthcare Provider Details

I. General information

NPI: 1912494873
Provider Name (Legal Business Name): THACH BAO JONATHAN NGUYEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9508 STOCKDALE HWY STE 150
BAKERSFIELD CA
93311-3623
US

IV. Provider business mailing address

9508 STOCKDALE HWY STE 150
BAKERSFIELD CA
93311-3623
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-7500
  • Fax: 661-663-7503
Mailing address:
  • Phone: 661-663-7500
  • Fax: 661-663-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA195490
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30293
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.141244
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: