Basic Information
| Provider Information | |||||||||
| NPI: | 1013991447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | BAO-TRAM | ||||||||
| MiddleName: | XUAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 PRESTON PARK BLVD | ||||||||
| Address2: | STE 1825 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750933656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728677862 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3901 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750757738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725966800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 212931 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | M4393 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 2069440 | 05 | MA | MEDICAID | J27632 | 01 | MA | BCBS MA | OTHER | 469348 | 01 | MA | TUFTS HEALTH PLAN | OTHER |