Healthcare Provider Details

I. General information

NPI: 1124125943
Provider Name (Legal Business Name): VANIA THANH NGUYEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 W JEFFERSON BLVD STE 302
LOS ANGELES CA
90066-7032
US

IV. Provider business mailing address

2020 SANTA MONICA BLVD STE 300
SANTA MONICA CA
90404-2013
US

V. Phone/Fax

Practice location:
  • Phone: 424-443-5600
  • Fax: 424-443-5606
Mailing address:
  • Phone: 310-582-7313
  • Fax: 310-315-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301087156
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA86445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: