Basic Information
| Provider Information | |||||||||
| NPI: | 1629144464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAO | ||||||||
| FirstName: | KEDY | ||||||||
| MiddleName: | YING | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAO | ||||||||
| OtherFirstName: | KEDY | ||||||||
| OtherMiddleName: | YING | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 S KRAEMER BLVD | ||||||||
| Address2: | #240 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149301351 | ||||||||
| FaxNumber: | 7149301361 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S KRAEMER BLVD | ||||||||
| Address2: | #240 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149301351 | ||||||||
| FaxNumber: | 7149301361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A4947 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.