MEDICARE: DR. JACQUES KPODONU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A72779	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00333876	OTHER	AZ	RAILROAD MEDICARE AHI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A72779	OTHER	CA	LICENSE
3	WCSKQ	OTHER	AZ	SUN HEALTH GROUP # AHI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1750339479	OTHER	CA	GROUP NPI

General Provider Information

NPI Number	:	1134152267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUES KPODONU M.D.

Provider Business Mailing Address
First Line	:	447 OLD NEWPORT BLVD. #200
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4257
Country	:	US
Telephone Number	:	949-650-3350
Fax Number	:	949-650-1274

Provider Business Practice Location Address
First Line	:	447 OLD NEWPORT BLVD. #200
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4257
Country	:	US
Telephone Number	:	949-650-3350
Fax Number	:	949-650-1274

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	03/07/2023

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