1124119979 NPI number — TIT SANG LI MD & NGA WAN WONG MD INC

Table of content: (NPI 1124119979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124119979 NPI number — TIT SANG LI MD & NGA WAN WONG MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIT SANG LI MD & NGA WAN WONG MD INC
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:
1124119979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6181 GLENEAGLES CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-5561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-898-9635
Provider Business Mailing Address Fax Number:
714-898-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6552 BOLSA AVE
Provider Second Line Business Practice Location Address:
SUITE N
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-898-9635
Provider Business Practice Location Address Fax Number:
714-898-9637
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
NGA
Authorized Official Middle Name:
WAN
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
714-898-9635

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A26311 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: A25684 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0005X , with the licence number: A26311 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0002451 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0002450 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".