Basic Information
| Provider Information | |||||||||
| NPI: | 1710964481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENG | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27871 MEDICAL CENTER RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493645090 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 27871 MEDICAL CENTER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493645090 | ||||||||
| FaxNumber: | 9495428710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | A64319 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00A643190 | 05 | CA | MEDICAID |