Provider Demographics
NPI:1013199348
Name:SANTA CRUZ MEDICAL CLINIC
Entity Type:Organization
Organization Name:SANTA CRUZ MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:BYONG
Authorized Official - Middle Name:K
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-361-1955
Mailing Address - Street 1:8703 STONEWALL RD
Mailing Address - Street 2:2B
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-8325
Mailing Address - Country:US
Mailing Address - Phone:703-361-1955
Mailing Address - Fax:703-361-3277
Practice Address - Street 1:8703 STONEWALL RD
Practice Address - Street 2:2B
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8325
Practice Address - Country:US
Practice Address - Phone:703-361-1955
Practice Address - Fax:703-361-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08625OtherMEDICARE GROUP