Provider Demographics
NPI:1154358760
Name:NGUYEN, DICH VAN (MD)
Entity type:Individual
Prefix:
First Name:DICH
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:PO BOX 29528
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30359
Mailing Address - Country:US
Mailing Address - Phone:404-766-4633
Mailing Address - Fax:404-766-1108
Practice Address - Street 1:4865 LAVISTA RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4436
Practice Address - Country:US
Practice Address - Phone:770-270-0290
Practice Address - Fax:770-723-0598
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000614116CMedicaid
GA01BDFZXMedicare ID - Type Unspecified
GA000614116CMedicaid