Healthcare Provider Details

I. General information

NPI: 1598178329
Provider Name (Legal Business Name): JINGYUN GAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 07/25/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 WATKINS MILL RD
GAITHERSBURG MD
20879-3301
US

IV. Provider business mailing address

1515 N VERMONT AVE
LOS ANGELES CA
90027-5337
US

V. Phone/Fax

Practice location:
  • Phone: 844-549-0597
  • Fax:
Mailing address:
  • Phone: 800-954-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA179320
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125064585
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0085023
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: