Provider Demographics
NPI:1104887785
Name:NGUYEN, THERESA TH (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:TH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 631568
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 N CHARLES ST
Practice Address - Street 2:SUITE 306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6800
Practice Address - Country:US
Practice Address - Phone:443-849-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD51824208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD720L38KKMedicare PIN
H09615Medicare UPIN