Healthcare Provider Details

I. General information

NPI: 1114361060
Provider Name (Legal Business Name): LEANN KHANH HOANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 280
RIVERSIDE CA
92505-3370
US

IV. Provider business mailing address

4234 RIVERWALK PKWY STE 280
RIVERSIDE CA
92505-3370
US

V. Phone/Fax

Practice location:
  • Phone: 951-785-7190
  • Fax: 951-688-7246
Mailing address:
  • Phone: 951-785-7190
  • Fax: 951-688-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA133825
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberA133825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: