Healthcare Provider Details

I. General information

NPI: 1811805062
Provider Name (Legal Business Name): BAO NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2246 DUNLOP ST
SAN DIEGO CA
92111-6302
US

IV. Provider business mailing address

2246 DUNLOP ST
SAN DIEGO CA
92111-6302
US

V. Phone/Fax

Practice location:
  • Phone: 858-436-6719
  • Fax:
Mailing address:
  • Phone: 858-436-6719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number598541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: