1720080294 NPI number — JACK LIANJIE DU, M.D., A MEDICAL CORPORATION

Table of content: (NPI 1720080294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720080294 NPI number — JACK LIANJIE DU, M.D., A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK LIANJIE DU, M.D., A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720080294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2913 EL CAMINO REAL
Provider Second Line Business Mailing Address:
#603
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92782-8909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-277-4200
Provider Business Mailing Address Fax Number:
714-384-3889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 W STEWART DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-771-8134
Provider Business Practice Location Address Fax Number:
714-744-8542
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DU
Authorized Official First Name:
JACK
Authorized Official Middle Name:
LIANJIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-771-8134

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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