Provider Demographics
NPI:1881726354
Name:FOO, EDMUND BONG LING (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:BONG LING
Last Name:FOO
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 1:1850 S AZUSA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6813
Mailing Address - Country:US
Mailing Address - Phone:626-913-2383
Mailing Address - Fax:626-913-2013
Practice Address - Street 1:1850 S AZUSA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6813
Practice Address - Country:US
Practice Address - Phone:626-913-2383
Practice Address - Fax:626-913-2013
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3668230Medicaid
CA00C400191Medicaid
CAC02628Medicare UPIN
CAC40019Medicare ID - Type UnspecifiedPROVIDER NUMBER