Provider Demographics
NPI:1649253691
Name:LUONG, KHOA CONG (DO)
Entity type:Individual
Prefix:DR
First Name:KHOA
Middle Name:CONG
Last Name:LUONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27300 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4802
Mailing Address - Country:US
Mailing Address - Phone:951-243-2018
Mailing Address - Fax:
Practice Address - Street 1:4755 DOHENY DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4030
Practice Address - Country:US
Practice Address - Phone:909-591-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7838207P00000X
MI5101013560207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3332971Medicaid
CA00AX78380Medicaid
MI0B56088072Medicare ID - Type Unspecified
CA00AX78380Medicaid
MI3332971Medicaid