Provider Demographics
NPI:1114923869
Name:NGUYEN, BACH VAN (MD)
Entity type:Individual
Prefix:DR
First Name:BACH
Middle Name:VAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-1125
Mailing Address - Country:US
Mailing Address - Phone:610-688-3184
Mailing Address - Fax:
Practice Address - Street 1:828 SNYDER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2310
Practice Address - Country:US
Practice Address - Phone:215-755-8220
Practice Address - Fax:215-755-8692
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-039485L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001123542-0003Medicaid
PA001123542OtherMEDICAL ASSISTANCE