Healthcare Provider Details

I. General information

NPI: 1366624892
Provider Name (Legal Business Name): THIENNGA P NGUYEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA P NGUYEN

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 MARTIN LUTHER KING JR WAY
OAKLAND CA
94612-1318
US

IV. Provider business mailing address

2221 MARTIN LUTHER KING JR WAY
OAKLAND CA
94612-1318
US

V. Phone/Fax

Practice location:
  • Phone: 510-267-7800
  • Fax: 510-267-7998
Mailing address:
  • Phone: 510-267-7800
  • Fax: 510-267-7998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101245292
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101245292
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0057327
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC152753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: