Healthcare Provider Details

I. General information

NPI: 1396011367
Provider Name (Legal Business Name): TAM K NGUYEN MEDICAL PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 04/22/2023
Certification Date: 04/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 BROOKHURST ST STE 100
GARDEN GROVE CA
92840-2848
US

IV. Provider business mailing address

12221 BROOKHURST ST STE 100
GARDEN GROVE CA
92840-2848
US

V. Phone/Fax

Practice location:
  • Phone: 714-805-8260
  • Fax: 714-908-8086
Mailing address:
  • Phone: 714-805-8260
  • Fax: 714-908-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA55848
License Number StateCA

VIII. Authorized Official

Name: DR. TAM K NGUYEN
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 714-757-3797