Healthcare Provider Details

I. General information

NPI: 1013329499
Provider Name (Legal Business Name): MY NGUYEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 12/30/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

11234 ANDERSON ST GME OFFICE WESTERLY SUITE 'C'
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-4000
  • Fax:
Mailing address:
  • Phone: 909-558-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A14630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: