Healthcare Provider Details

I. General information

NPI: 1831296656
Provider Name (Legal Business Name): THANH M NGUYEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12086 FORT CAROLINE RD STE 401
JACKSONVILLE FL
32225-2687
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-565-1271
  • Fax:
Mailing address:
  • Phone: 904-824-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberME101652
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME101652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: