Healthcare Provider Details

I. General information

NPI: 1780638528
Provider Name (Legal Business Name): SIMON JIANG M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 S ATLANTIC BLVD STE 106
MONTEREY PARK CA
91754-4734
US

IV. Provider business mailing address

1335 S SAN GABRIEL BLVD
SAN MARINO CA
91108-2703
US

V. Phone/Fax

Practice location:
  • Phone: 213-458-3132
  • Fax: 213-234-4542
Mailing address:
  • Phone: 213-458-3132
  • Fax: 213-234-4542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA69991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA69991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: