=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720013626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHUC D NGUYEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 FANNIN ST STE 170
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-325-6500
-----------------------------------------------------
Fax | 713-512-2236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6410 FANNIN ST STE 170
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-325-6500
-----------------------------------------------------
Fax | 713-512-2236
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | L8454
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------