Healthcare Provider Details

I. General information

NPI: 1134331549
Provider Name (Legal Business Name): TRUNG TAN NGUYEN D.O.,M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2007
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 MEDICAL CENTER DR E # 212
CLOVIS CA
93611-6889
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-451-3676
  • Fax: 559-451-3680
Mailing address:
  • Phone: 559-443-2682
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A10394
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number20A10394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: