Healthcare Provider Details

I. General information

NPI: 1710332952
Provider Name (Legal Business Name): NGUYEN DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 10/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MAIN ST SUITE 201
HUNTINGTON NY
11743-6918
US

IV. Provider business mailing address

PO BOX 1064
EAST NORTHPORT NY
11731-0543
US

V. Phone/Fax

Practice location:
  • Phone: 631-403-2375
  • Fax: 206-339-7108
Mailing address:
  • Phone: 631-403-2375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number247136
License Number StateNY

VIII. Authorized Official

Name: CHAU NGUYEN
Title or Position: PRESIDENT
Credential: MD
Phone: 631-403-2375