Provider Demographics
NPI:1023205010
Name:JIMMY C. HUANG, D.O. A PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:JIMMY C. HUANG, D.O. A PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUANG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-292-0211
Mailing Address - Street 1:1158 26TH STREET
Mailing Address - Street 2:SUITE 570
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-453-3668
Mailing Address - Fax:310-453-3634
Practice Address - Street 1:2210 SANTA MONICA BLVD.
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-1708
Practice Address - Fax:310-828-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6713207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX67131Medicaid
CAOOAX67131Medicaid
CAOOAX67131Medicaid
CA00AX67131Medicaid