Healthcare Provider Details

I. General information

NPI: 1821082421
Provider Name (Legal Business Name): KHOA DANG NGUYEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR ROAD
STATESBORO GA
30458
US

IV. Provider business mailing address

P.O. BOX 3578
AUGUSTA GA
30914-3578
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-1533
  • Fax: 912-871-2396
Mailing address:
  • Phone: 706-737-4575
  • Fax: 706-731-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number053793
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number053793
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number053793
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number053793
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number053793
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number53793
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number053793
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number053793
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25IA12514200
License Number StateNJ
# 10
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number53793
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: