Provider Demographics
NPI:1306801188
Name:JACK C YANG MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:JACK C YANG MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-255-1440
Mailing Address - Street 1:4077 5TH AVE
Mailing Address - Street 2:MER 62
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2105
Mailing Address - Country:US
Mailing Address - Phone:619-255-1440
Mailing Address - Fax:888-900-0442
Practice Address - Street 1:4033 3RD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2117
Practice Address - Country:US
Practice Address - Phone:619-255-1440
Practice Address - Fax:888-900-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG730022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G730022Medicaid
CA00G730022Medicaid