Healthcare Provider Details

I. General information

NPI: 1285969162
Provider Name (Legal Business Name): LONG THANH NGUYENDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR MCHE-MDM
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR MCHE-MDM
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-5000
  • Fax: 210-916-2777
Mailing address:
  • Phone: 210-916-5000
  • Fax: 210-916-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number65981
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC162879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: