=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225231491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY CHUANG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 03/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 WATERWORKS WAY STE 225
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-525-5588
-----------------------------------------------------
Fax | 714-525-5193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21088 BLOSSOM WAY
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-657-7636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MT183129
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MD2009-0677
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MD 60105559
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | A105856
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------