=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912910357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE KONG M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 11/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20627 GOLDEN SPRINGS DR STE 1B
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-480-0200
-----------------------------------------------------
Fax | 909-480-0201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 866 S WESTMORELAND AVE STE 101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90005-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-821-5675
-----------------------------------------------------
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 | A97227
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------