=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700877842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW J HONG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31001 RANCHO VIEJO RD. SUITE 200
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-661-9611
-----------------------------------------------------
Fax | 949-443-6200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17360 BROOKHURST ST ATTN: MCMF - CREDENTIALING DEPT.
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A80562
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------