Healthcare Provider Details

I. General information

NPI: 1487995841
Provider Name (Legal Business Name): JACK H M KWAAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 OCANA AVE
LONG BEACH CA
90815-3221
US

IV. Provider business mailing address

2141 OCANA AVE
LONG BEACH CA
90815-3221
US

V. Phone/Fax

Practice location:
  • Phone: 562-598-7897
  • Fax:
Mailing address:
  • Phone: 562-598-7897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberAFE 22071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: