Provider Demographics
NPI:1972078764
Name:NGUYEN, JIMMY KHANH
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:KHANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JIMMY
Other - Middle Name:KHANH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:6103 NAURU ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5646
Mailing Address - Country:US
Mailing Address - Phone:310-897-9686
Mailing Address - Fax:
Practice Address - Street 1:6103 NAURU ST
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5646
Practice Address - Country:US
Practice Address - Phone:310-897-9686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26081208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation