Healthcare Provider Details

I. General information

NPI: 1053706309
Provider Name (Legal Business Name): AARON LIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 VALLEY VISTA DR ST JUDE HERITAGE MEDICAL GROUP
DIAMOND BAR CA
91765
US

IV. Provider business mailing address

1514 VALLEY VISTA DR
DIAMOND BAR CA
91765-3929
US

V. Phone/Fax

Practice location:
  • Phone: 909-860-1144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125066917
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.146095
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A16396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: