Provider Demographics
NPI:1780638528
Name:JIANG, SIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:JIANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 S SAN GABRIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2703
Mailing Address - Country:US
Mailing Address - Phone:213-458-3132
Mailing Address - Fax:213-234-4542
Practice Address - Street 1:925 S ATLANTIC BLVD STE 106
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4734
Practice Address - Country:US
Practice Address - Phone:213-458-3132
Practice Address - Fax:213-234-4542
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69991208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A699911Medicaid
CA00A699910Medicaid
CA00A699910Medicaid
CAWA69991AMedicare PIN
CA00A699911Medicaid