Provider Demographics
NPI:1144266883
Name:NGUYEN, TRUNG NAM (DO)
Entity type:Individual
Prefix:
First Name:TRUNG
Middle Name:NAM
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 1:120 E SOUTH TOWN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4747
Mailing Address - Country:US
Mailing Address - Phone:903-592-5670
Mailing Address - Fax:903-209-2888
Practice Address - Street 1:120 E SOUTH TOWN DR STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4747
Practice Address - Country:US
Practice Address - Phone:903-592-5670
Practice Address - Fax:903-209-2888
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5847207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157323007Medicaid
TX157323012Medicaid
TX75-0818167-048OtherTRICARE
TX75-2616977-002OtherTRICARE
TXTIN PLUS 005OtherTRICARE JACKSONVILLE LOCATION
TX0096NWOtherBCBS
TX157323011Medicaid
TXP00724999OtherRAIL ROAD
TXTIN PLUS 015OtherTRICARE TYLER LOCATION
TX75-2616977-001OtherTRICARE
TX8DU788OtherBCBS
TXTIN PLUS 044OtherTRICARE WINNSBORO LOCATION
TX75-2616977-028OtherTRICARE
TX8DU787OtherBCBS
TX157323009Medicaid
TX157323010Medicaid
TXP00654697OtherRAIL ROAD
TXP01092668OtherRAIL ROAD
TX157323009Medicaid
TX316095YNSXMedicare PIN
TXP00654697OtherRAIL ROAD
TX612696Medicare PIN
TX157323007Medicaid
TX8L0987Medicare Oscar/Certification
TX8L3835Medicare Oscar/Certification
TXP00448205Medicare PIN