Healthcare Provider Details

I. General information

NPI: 1861848061
Provider Name (Legal Business Name): BAO XUAN NGUYEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 E MARSHALL AVE STE 5007
LONGVIEW TX
75601-5554
US

IV. Provider business mailing address

703 E MARSHALL AVE STE 5007
LONGVIEW TX
75601-5554
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-4882
  • Fax:
Mailing address:
  • Phone: 903-315-4500
  • Fax: 903-502-6086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number15145
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberT4808
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberT4808
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20A19650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: