Healthcare Provider Details

I. General information

NPI: 1518987965
Provider Name (Legal Business Name): JIAOTI HUANG MD, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE B-186
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-1355
  • Fax:
Mailing address:
  • Phone: 310-267-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number211805
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC53385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: