Healthcare Provider Details

I. General information

NPI: 1114411352
Provider Name (Legal Business Name): JIN WEN SUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N TUSTIN AVE STE 109
SANTA ANA CA
92705-6501
US

IV. Provider business mailing address

PO BOX 3428
TUSTIN CA
92781-3428
US

V. Phone/Fax

Practice location:
  • Phone: 714-954-1182
  • Fax: 714-953-3425
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberA165749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: