Healthcare Provider Details

I. General information

NPI: 1124274998
Provider Name (Legal Business Name): JEFFREY HUANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 HUNTINGTON DR SUITE D
SAN MARINO CA
91108-2357
US

IV. Provider business mailing address

103 N GARFIELD AVE STE E
ALHAMBRA CA
91801-3578
US

V. Phone/Fax

Practice location:
  • Phone: 626-799-2075
  • Fax: 626-790-4554
Mailing address:
  • Phone: 626-799-2075
  • Fax: 626-790-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberSL0583
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20A11984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: