Basic Information
| Provider Information | |||||||||
| NPI: | 1538197082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HONG | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2858 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935392858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617296854 | ||||||||
| FaxNumber: | 6617296864 | ||||||||
| Practice Location | |||||||||
| Address1: | 44301 LORIMER AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619401110 | ||||||||
| FaxNumber: | 6617236402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 05/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A31851 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | AH1074309 | 01 | DEA | OTHER | 00A318510 | 05 | CA | MEDICAID | 050066604 | 01 | CA | RAILROAD MEDICARE | OTHER | 00A318510 | 01 | CA | BLUE SHIELD OF CA | OTHER |