Basic Information
| Provider Information | |||||||||
| NPI: | 1467834572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | KHOA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | KHOA | ||||||||
| OtherMiddleName: | ANH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2007 PALM BEACH LAKES BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334096501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614208555 | ||||||||
| FaxNumber: | 5614208550 | ||||||||
| Practice Location | |||||||||
| Address1: | 9671 GLADIOLUS DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339087684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399392246 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X | OS15310 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 208D00000X | OS15310 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.