Provider Demographics
NPI:1992309009
Name:NGO, MAI DUYEN
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:DUYEN
Last Name:NGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9721 BIRDVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6299
Mailing Address - Country:US
Mailing Address - Phone:817-689-4653
Mailing Address - Fax:
Practice Address - Street 1:9721 BIRDVILLE WAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6299
Practice Address - Country:US
Practice Address - Phone:817-689-4653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN1881792638OtherNPI
TXW112590872OtherAETNA INSURANCE