Provider Demographics
NPI:1932400686
Name:KWANHO CHONG, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KWANHO CHONG, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KWANHO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-522-9018
Mailing Address - Street 1:1158 ROADRUNNER WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3158
Mailing Address - Country:US
Mailing Address - Phone:805-522-9018
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:1158 ROADRUNNER WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3158
Practice Address - Country:US
Practice Address - Phone:805-522-9018
Practice Address - Fax:951-272-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG849682086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G849680Medicaid
CAG84968OtherCA MEDICAL LICENSE
CAG84968Medicare PIN
CAG84968OtherCA MEDICAL LICENSE