Healthcare Provider Details

I. General information

NPI: 1689693749
Provider Name (Legal Business Name): TAO T NGUYEN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6043 ATLANTIC BLVD
MAYWOOD CA
90270-3118
US

IV. Provider business mailing address

PO BOX 3780
LA HABRA CA
90632-3780
US

V. Phone/Fax

Practice location:
  • Phone: 323-583-6516
  • Fax: 323-583-0802
Mailing address:
  • Phone: 323-583-6516
  • Fax: 323-583-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA44456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00A444561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: