Healthcare Provider Details

I. General information

NPI: 1609132448
Provider Name (Legal Business Name): J PUANGCO M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21932 ANNETTE AVE
LAKE FOREST CA
92630-1811
US

IV. Provider business mailing address

21932 ANNETTE AVE
LAKE FOREST CA
92630-1811
US

V. Phone/Fax

Practice location:
  • Phone: 323-375-4266
  • Fax:
Mailing address:
  • Phone: 323-375-4266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License NumberA91074
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberA91074
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA91074
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA91074
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE PUANGCO
Title or Position: CEO
Credential: M.D.
Phone: 323-375-4266