Healthcare Provider Details

I. General information

NPI: 1972709558
Provider Name (Legal Business Name): HUONG-ANH NGO LONG, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 7TH ST
SAN PEDRO CA
90732-3505
US

IV. Provider business mailing address

1621 W 25TH ST #161
SAN PEDRO CA
90732-4301
US

V. Phone/Fax

Practice location:
  • Phone: 310-514-5208
  • Fax: 310-514-5374
Mailing address:
  • Phone: 310-514-5208
  • Fax: 310-514-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG62453
License Number StateCA

VIII. Authorized Official

Name: DR. HUONG-ANH NGO LONG
Title or Position: OWNER
Credential: M.D.
Phone: 310-514-5208