Healthcare Provider Details

I. General information

NPI: 1477188696
Provider Name (Legal Business Name): CHARLES NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 SAMARITAN DR
SAN JOSE CA
95124-3907
US

IV. Provider business mailing address

2460 SAMARITAN DR
SAN JOSE CA
95124-3907
US

V. Phone/Fax

Practice location:
  • Phone: 408-871-5220
  • Fax:
Mailing address:
  • Phone: 650-643-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA206962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: