Healthcare Provider Details

I. General information

NPI: 1063826899
Provider Name (Legal Business Name): JOHNNY THANH SON NGUYEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610
US

IV. Provider business mailing address

PO BOX 100254
GAINESVILLE FL
32610-0254
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax:
Mailing address:
  • Phone: 352-273-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS15404
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberBP1-0050304
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: