Healthcare Provider Details

I. General information

NPI: 1740880475
Provider Name (Legal Business Name): KHANG DUY BAO NGUYEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 EAST 41ST STREET
TULSA OK
74135
US

IV. Provider business mailing address

4502 EAST 41ST STREET
TULSA OK
74135
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4400
  • Fax: 918-619-4152
Mailing address:
  • Phone: 918-619-4400
  • Fax: 918-619-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1130R
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: