Provider Demographics
NPI:1710964481
Name:FENG, JACK C (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:FENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27871 MEDICAL CENTER RD STE 240
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6406
Mailing Address - Country:US
Mailing Address - Phone:949-364-5090
Mailing Address - Fax:
Practice Address - Street 1:27871 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6404
Practice Address - Country:US
Practice Address - Phone:949-364-5090
Practice Address - Fax:949-542-8710
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64319207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A643190Medicaid
CAWA64319AMedicare PIN
CAH61358Medicare UPIN
CAGW025ZMedicare PIN