Provider Demographics
NPI:1134152267
Name:KPODONU, JACQUES (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:
Last Name:KPODONU
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 1:447 OLD NEWPORT BLVD. #200
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4257
Mailing Address - Country:US
Mailing Address - Phone:949-650-3350
Mailing Address - Fax:949-650-1274
Practice Address - Street 1:447 OLD NEWPORT BLVD. #200
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4257
Practice Address - Country:US
Practice Address - Phone:949-650-3350
Practice Address - Fax:949-650-1274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA72779OtherLICENSE
AZP00333876OtherRAILROAD MEDICARE AHI
AZWCSKQOtherSUN HEALTH GROUP # AHI
AZ141743Medicaid
CA1750339479OtherGROUP NPI
CA1750339479OtherGROUP NPI
AZI4469Medicare UPIN
AZ141743Medicaid
AZWCSKQOtherSUN HEALTH GROUP # AHI