1417392663 NPI number — MIMMIE KWONG M.D.

Table of content: MIMMIE KWONG M.D. (NPI 1417392663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417392663 NPI number — MIMMIE KWONG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KWONG
Provider First Name:
MIMMIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1417392663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2335 STOCKTON BLVD., 6TH FLOOR
Provider Second Line Business Mailing Address:
NORTH ADDITION OFFICE BUILDING
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-734-2028
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4860 Y ST STE 2100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-3800
Provider Business Practice Location Address Fax Number:
916-734-3801
Provider Enumeration Date:
05/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  A140004 , 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)





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