Provider Demographics
NPI:1720080294
Name:JACK LIANJIE DU, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JACK LIANJIE DU, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LIANJIE
Authorized Official - Last Name:DU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-771-8134
Mailing Address - Street 1:2913 EL CAMINO REAL
Mailing Address - Street 2:#603
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8909
Mailing Address - Country:US
Mailing Address - Phone:714-277-4200
Mailing Address - Fax:714-384-3889
Practice Address - Street 1:1100 W STEWART DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3849
Practice Address - Country:US
Practice Address - Phone:714-771-8134
Practice Address - Fax:714-744-8542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17838Medicare ID - Type Unspecified