1174257414 NPI number — DONGWHAN DUSTIN IM PHYSICIAN ASSISTANT

Table of content: DONGWHAN DUSTIN IM PHYSICIAN ASSISTANT (NPI 1174257414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174257414 NPI number — DONGWHAN DUSTIN IM PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IM
Provider First Name:
DONGWHAN
Provider Middle Name:
DUSTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

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:
1174257414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 S FREMONT AVE BLDG A-11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALHAMBRA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91803-8800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 N TUSTIN AVE STE 507
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-566-8688
Provider Business Practice Location Address Fax Number:
949-566-8656
Provider Enumeration Date:
07/12/2022

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: 363A00000X , 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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