Healthcare Provider Details

I. General information

NPI: 1346474582
Provider Name (Legal Business Name): DUSTIN DUY NGUYEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2009
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 NW WATER LILY PL
CAMAS WA
98607-8843
US

IV. Provider business mailing address

816 W CANNON ST
FORT WORTH TX
76104-3146
US

V. Phone/Fax

Practice location:
  • Phone: 817-881-2765
  • Fax:
Mailing address:
  • Phone: 817-321-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberQ4820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: