Provider Demographics
NPI:1306906508
Name:FORMOSA MEDICAL GROUP
Entity type:Organization
Organization Name:FORMOSA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:KUANG
Authorized Official - Last Name:HUANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-284-6408
Mailing Address - Street 1:850 S ATLANTIC BLVD
Mailing Address - Street 2:#304
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4730
Mailing Address - Country:US
Mailing Address - Phone:626-284-6408
Mailing Address - Fax:626-284-1201
Practice Address - Street 1:850 S ATLANTIC BLVD
Practice Address - Street 2:#304
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4730
Practice Address - Country:US
Practice Address - Phone:626-284-6408
Practice Address - Fax:626-284-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA417562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11647Medicare ID - Type Unspecified
A88574Medicare UPIN