Healthcare Provider Details

I. General information

NPI: 1114540572
Provider Name (Legal Business Name): DUSTIN NGUYEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E EISENHOWER PKWY
ANN ARBOR MI
48108-3302
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-539-5080
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301509104
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: