=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710366828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. QUEEN FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 05/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1675 BURDETTE DR STE 20
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95121-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-274-6944
-----------------------------------------------------
Fax | 408-274-2258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1675 BURDETTE DR STE 20
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95121-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-274-6944
-----------------------------------------------------
Fax | 408-274-2258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWCER
-----------------------------------------------------
Name | QUYNH QUEEN NGUYEN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 408-274-6944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 20A8237
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------