Provider Demographics
NPI:1417392663
Name:KWONG, MIMMIE (MD)
Entity Type:Individual
Prefix:
First Name:MIMMIE
Middle Name:
Last Name:KWONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2335 STOCKTON BLVD., 6TH FLOOR
Mailing Address - Street 2:NORTH ADDITION OFFICE BUILDING
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1418
Mailing Address - Country:US
Mailing Address - Phone:916-734-2028
Mailing Address - Fax:
Practice Address - Street 1:4860 Y ST STE 2100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-3800
Practice Address - Fax:916-734-3801
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA1400042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery