Provider Demographics
NPI:1083949853
Name:HONG, JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:HONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-525-6485
Mailing Address - Fax:707-573-6918
Practice Address - Street 1:2725 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2805
Practice Address - Country:US
Practice Address - Phone:707-545-4537
Practice Address - Fax:707-545-6726
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110009207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01774455OtherRAILROAD MEDICARE
CA1083949853Medicaid
CAP01774455OtherRAILROAD MEDICARE
CACA230674Medicare PIN