Healthcare Provider Details

I. General information

NPI: 1720080294
Provider Name (Legal Business Name): JACK LIANJIE DU, M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W STEWART DR
ORANGE CA
92868-3849
US

IV. Provider business mailing address

2913 EL CAMINO REAL #603
TUSTIN CA
92782-8909
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-8134
  • Fax: 714-744-8542
Mailing address:
  • Phone: 714-277-4200
  • Fax: 714-384-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK LIANJIE DU
Title or Position: OWNER
Credential: M.D.
Phone: 714-771-8134