Healthcare Provider Details

I. General information

NPI: 1295700326
Provider Name (Legal Business Name): BAC X NGUYEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 DELSEA DR N
GLASSBORO NJ
08028-1444
US

IV. Provider business mailing address

1120 DELSEA DR N
GLASSBORO NJ
08028-1444
US

V. Phone/Fax

Practice location:
  • Phone: 856-582-0500
  • Fax: 856-218-9607
Mailing address:
  • Phone: 856-582-0500
  • Fax: 856-218-9607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA07262300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: