Basic Information
| Provider Information | |||||||||
| NPI: | 1255331385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DU | ||||||||
| FirstName: | LIANJIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DU | ||||||||
| OtherFirstName: | JACK | ||||||||
| OtherMiddleName: | LIANJIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2913 EL CAMINO REAL | ||||||||
| Address2: | #603 | ||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927828909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142774200 | ||||||||
| FaxNumber: | 7143843889 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 W STEWART DR | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145649659 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A84426 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | A84426 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A844260 | 05 | CA | MEDICAID |