Healthcare Provider Details

I. General information

NPI: 1790103497
Provider Name (Legal Business Name): TAI TAN NGUYEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 S 6TH ST
OAK CREEK WI
53154-2010
US

IV. Provider business mailing address

7901 S 6TH ST
OAK CREEK WI
53154-2010
US

V. Phone/Fax

Practice location:
  • Phone: 414-346-8000
  • Fax: 414-346-8010
Mailing address:
  • Phone: 414-346-8000
  • Fax: 414-346-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64694-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: