Basic Information
Provider Information
NPI: 1003141102
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NGUYEN
FirstName: KHOI
MiddleName: DUC
NamePrefix:  
NameSuffix:  
Credential: MD, DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1295 FULBAR CT
Address2:  
City: SAN JOSE
State: CA
PostalCode: 951323022
CountryCode: US
TelephoneNumber: 4084894832
FaxNumber:  
Practice Location
Address1: 3800 JANES RD
Address2:  
City: ARCATA
State: CA
PostalCode: 955214742
CountryCode: US
TelephoneNumber: 4084894832
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/07/2009
LastUpdateDate: 02/14/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X20A 11589CAY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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