Provider Demographics
NPI:1386642866
Name:NGUYEN, PHU THIEN (DO)
Entity type:Individual
Prefix:DR
First Name:PHU
Middle Name:THIEN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12555 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1902
Mailing Address - Country:US
Mailing Address - Phone:714-741-0501
Mailing Address - Fax:714-741-0095
Practice Address - Street 1:12555 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1902
Practice Address - Country:US
Practice Address - Phone:714-741-0501
Practice Address - Fax:714-741-0095
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7161207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX71610Medicaid
CA00AX71610Medicaid
CAW17836Medicare ID - Type UnspecifiedGROUP MEDICARE #/PIN
CAW20A7161AMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #/PIN