Healthcare Provider Details

I. General information

NPI: 1922499714
Provider Name (Legal Business Name): KEVIN JUN-PAY FANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2015
Last Update Date: 02/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 68
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

1520 RODNEY DR APT 314
LOS ANGELES CA
90027-5323
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2122
  • Fax:
Mailing address:
  • Phone: 301-529-9959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA134401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: