Basic Information
| Provider Information | |||||||||
| NPI: | 1841398807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENTF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3661 NW 64TH LN | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326538870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523791437 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867546373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | CAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIMARY CARE PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 3867553016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | ME74202 | FL | Y | Hospitals | General Acute Care Hospital |
No ID Information.