1558503169 NPI number — THUY T M NGUYEN M D INC

Table of content: JULIANNA MARIE POTTER NP (NPI 1205677143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558503169 NPI number — THUY T M NGUYEN M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THUY T M NGUYEN M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558503169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5131 NELLIE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91739-5132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-841-4181
Provider Business Mailing Address Fax Number:
520-843-4181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8891 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91763-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-297-3361
Provider Business Practice Location Address Fax Number:
520-843-4181
Provider Enumeration Date:
03/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VO
Authorized Official First Name:
THUY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
213-841-4181

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  75293 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A803220 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A803220 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00205726 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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