Basic Information
| Provider Information | |||||||||
| NPI: | 1902981582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | SON | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075336836 | ||||||||
| FaxNumber: | 4072329316 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025801000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K2085 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | K2085 | 01 | TX | MEDICAL LICENSE | OTHER | 111888707 | 05 | TX | MEDICAID |