Provider Demographics
NPI:1669013181
Name:DONG, CANG KIM
Entity Type:Individual
Prefix:
First Name:CANG
Middle Name:KIM
Last Name:DONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 MAYHEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-2243
Mailing Address - Country:US
Mailing Address - Phone:408-332-8276
Mailing Address - Fax:
Practice Address - Street 1:1238 MAYHEW DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-2243
Practice Address - Country:US
Practice Address - Phone:408-332-8276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care