Basic Information
| Provider Information | |||||||||
| NPI: | 1720080294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACK LIANJIE DU, M.D., A MEDICAL CORPORATION | ||||||||
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| 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: | 7147718134 | ||||||||
| FaxNumber: | 7147448542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | DU | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | LIANJIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7147718134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.