Basic Information
Provider Information | |||||||||
NPI: | 1922585645 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MD24 SJ, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PLAZA TOWER I 600 ANTON BLVD, | ||||||||
Address2: | SUITE 1100, | ||||||||
City: | COSTA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 92626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233747774 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 JOSE FIGUERES AVE STE 180 | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951161586 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233747774 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2018 | ||||||||
LastUpdateDate: | 05/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NGUYEN | ||||||||
AuthorizedOfficialFirstName: | LINH | ||||||||
AuthorizedOfficialMiddleName: | CAO | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6233747774 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.