Provider Demographics
NPI:1174516892
Name:NGUYEN, THOMAS BAO (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BAO
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5597
Mailing Address - Fax:
Practice Address - Street 1:1846 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2822
Practice Address - Country:US
Practice Address - Phone:321-361-5597
Practice Address - Fax:321-434-7035
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2025-09-12
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
OH72672207R00000X
FLME135747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherHFMG
OH2022788Medicaid
OH0838091Medicare PIN
OHH369932Medicare PIN