Healthcare Provider Details

I. General information

NPI: 1053305359
Provider Name (Legal Business Name): JI-GUANG JIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N TUSTIN AVE
SANTA ANA CA
92705-3502
US

IV. Provider business mailing address

PO BOX 1809
ORANGE CA
92856-0809
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-3500
  • Fax:
Mailing address:
  • Phone: 714-560-1580
  • Fax: 714-560-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA74174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: