Provider Demographics
NPI:1144273491
Name:NGUYEN, TAN KHAC (MD)
Entity type:Individual
Prefix:
First Name:TAN
Middle Name:KHAC
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 1:1310 SAN BERNARDINO RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4979
Mailing Address - Country:US
Mailing Address - Phone:909-946-8600
Mailing Address - Fax:909-946-8604
Practice Address - Street 1:1310 SAN BERNARDINO RD
Practice Address - Street 2:SUITE 207
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4979
Practice Address - Country:US
Practice Address - Phone:909-946-8600
Practice Address - Fax:909-946-8604
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70331207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00614352OtherRAILLROAD MEDICARE
CAH21605Medicare UPIN
CAWA7033IKMedicare PIN