Basic Information
| Provider Information | |||||||||
| NPI: | 1902078942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | VAN KHANH | ||||||||
| MiddleName: | THI | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | KHANH VAN | ||||||||
| OtherMiddleName: | THI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1622 E SEDONA DR | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928663303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142356135 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8599 HAVEN AVE. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9099197288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A88003 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.