Provider Demographics
NPI:1396741351
Name:NGUYEN, TIEN QUANG (MD)
Entity type:Individual
Prefix:DR
First Name:TIEN
Middle Name:QUANG
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 1:17271 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3701
Mailing Address - Country:US
Mailing Address - Phone:714-531-2966
Mailing Address - Fax:714-531-3495
Practice Address - Street 1:17271 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3701
Practice Address - Country:US
Practice Address - Phone:714-531-2966
Practice Address - Fax:714-531-3495
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20979207N00000X
CAG50454207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG50454Medicare ID - Type Unspecified
CAC36113Medicare UPIN