=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700304664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD NGUYEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2017
-----------------------------------------------------
Last Update Date | 04/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2051 MARENGO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-209-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 VINE ST APT C
-----------------------------------------------------
City | ALHAMBRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91801-6601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-712-0710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A181390
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------