Healthcare Provider Details

I. General information

NPI: 1437654340
Provider Name (Legal Business Name): NATHAN KWONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 12/23/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST STREET
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

17360 BROOKHURST STREET
FOUNTAIN VALLEY CA
92708
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-1797
  • Fax: 714-665-4680
Mailing address:
  • Phone: 714-665-1797
  • Fax: 714-665-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA173450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: