Healthcare Provider Details

I. General information

NPI: 1114153459
Provider Name (Legal Business Name): VIET QUOC NGUYEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 NE 139TH ST
VANCOUVER WA
98686-2719
US

IV. Provider business mailing address

PO BOX 873010
VANCOUVER WA
98687-3010
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax:
Mailing address:
  • Phone: 360-882-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD60359915
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301094116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: