Basic Information
| Provider Information | |||||||||
| NPI: | 1235796129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | TO-LAM | ||||||||
| MiddleName: | THACH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 W PRATT ST APT 1408 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404163343 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103288667 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2019 | ||||||||
| LastUpdateDate: | 05/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.