Healthcare Provider Details

I. General information

NPI: 1255019345
Provider Name (Legal Business Name): TIMOTHY MICHAEL NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5473 KEARNY VILLA RD
SAN DIEGO CA
92123-1150
US

IV. Provider business mailing address

5473 KEARNY VILLA RD
SAN DIEGO CA
92123-1150
US

V. Phone/Fax

Practice location:
  • Phone: 858-298-8707
  • Fax:
Mailing address:
  • Phone: 858-298-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: