Healthcare Provider Details

I. General information

NPI: 1194803965
Provider Name (Legal Business Name): MYNGOC THI NGUYEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYNGOC THI NGUYEN MD

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 COLBY ST STE 118
BERKELEY CA
94705-2059
US

IV. Provider business mailing address

275 W MACARTHUR
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-2316
  • Fax: 510-704-8346
Mailing address:
  • Phone: 510-752-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberG50040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: