Healthcare Provider Details

I. General information

NPI: 1518245596
Provider Name (Legal Business Name): TIEN MINH NGUYEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

5060 N BROADWAY ST
CHICAGO IL
60640-3007
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2128
  • Fax:
Mailing address:
  • Phone: 773-293-4200
  • Fax: 773-293-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036135545
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: