MEDICARE: BAO VINH NGUYEN PHUC M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K8667	TX

General Provider Information

NPI Number	:	1518094317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAO VINH NGUYEN PHUC M.D.

Provider Business Mailing Address
First Line	:	1413 N BEACH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-6614
Country	:	US
Telephone Number	:	817-831-0034
Fax Number	:	817-831-2030

Provider Business Practice Location Address
First Line	:	1413 N BEACH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-6614
Country	:	US
Telephone Number	:	817-831-0034
Fax Number	:	817-831-2030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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