Basic Information
| Provider Information | |||||||||
| NPI: | 1104916253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONG | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 EXECUTIVE PARK | ||||||||
| Address2: | STE 155 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926144733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 8004097005 | ||||||||
| Practice Location | |||||||||
| Address1: | 168 N BRENT ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525093 | ||||||||
| FaxNumber: | 8056413965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A81074 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A810740 | 01 | CA | BC BS OF CA | OTHER | 1104916253 | 05 | CA | MEDICAID |