Provider Demographics
NPI:1215941778
Name:NGUYEN, SON THAI (MD)
Entity type:Individual
Prefix:
First Name:SON
Middle Name:THAI
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 1:19582 BEACH BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2996
Mailing Address - Country:US
Mailing Address - Phone:714-378-2404
Mailing Address - Fax:
Practice Address - Street 1:19582 BEACH BLVD
Practice Address - Street 2:STE 307
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2996
Practice Address - Country:US
Practice Address - Phone:714-378-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F50316Medicare UPIN