Healthcare Provider Details

I. General information

NPI: 1083648687
Provider Name (Legal Business Name): TSUNG CHIEH JACKSON WU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACKSON WU MD

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 430
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-7274
  • Fax:
Mailing address:
  • Phone: 310-794-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberA46040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: