Basic Information
| Provider Information | |||||||||
| NPI: | 1922162221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | THANH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ALBANY ST FL G | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021193791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 840 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176386610 | ||||||||
| FaxNumber: | 6176386616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084V0102X | 220609 | MA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | 220609 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | 220609 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3083378 | 05 | NH | MEDICAID | 110077214A | 05 | MA | MEDICAID | 1922162221 | 05 | ME | MEDICAID |