Basic Information
| Provider Information | |||||||||
| NPI: | 1912494873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | THACH BAO JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUMMIT AVENUE | ||||||||
| Address2: | MSO PHYSICIAN BILLING | ||||||||
| City: | STEUBENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439522667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402837597 | ||||||||
| FaxNumber: | 7402837807 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WINTERSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439533733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402662930 | ||||||||
| FaxNumber: | 7402662931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 30293 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35.141244 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0446768 | 05 | OH | MEDICAID |