Provider Demographics
NPI:1194913756
Name:NGUYEN, BAO THAI (MD)
Entity type:Individual
Prefix:DR
First Name:BAO
Middle Name:THAI
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:555 PIER AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3839
Mailing Address - Country:US
Mailing Address - Phone:424-488-0500
Mailing Address - Fax:424-488-0498
Practice Address - Street 1:555 PIER AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3839
Practice Address - Country:US
Practice Address - Phone:424-488-0500
Practice Address - Fax:424-488-0498
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95636208100000X
NY252803-2208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194913756OtherNPI
NYG400006164Medicare PIN