Provider Demographics
NPI:1194110700
Name:RAN, CONG
Entity type:Individual
Prefix:
First Name:CONG
Middle Name:
Last Name:RAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:1317 5TH ST STE 300
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1433
Practice Address - Country:US
Practice Address - Phone:310-434-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA167718207YS0123X, 207YX0007X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program