Basic Information
| Provider Information | |||||||||
| NPI: | 1831296656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | THANH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12086 FORT CAROLINE RD | ||||||||
| Address2: | STE 401 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322252687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045651271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | ME101652 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 208000000X | ME101652 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 41503 | 01 | FL | BCBS / FLORIDA BLUE | OTHER | 000031000 | 05 | FL | MEDICAID |