Basic Information
| Provider Information | |||||||||
| NPI: | 1235216417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TONY TAN NGUYEN MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 WASHINGTON ST | ||||||||
| Address2: | #116 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587541114 | ||||||||
| FaxNumber: | 8587541114 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 WASHINGTON ST | ||||||||
| Address2: | #116 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662842771 | ||||||||
| FaxNumber: | 8003341041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | TAN | ||||||||
| AuthorizedOfficialMiddleName: | THE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8587541114 | ||||||||
| 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 | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G671191 | 05 | CA | MEDICAID |