Provider Demographics
NPI:1386812394
Name:SOOMCHUNGMDONCOLOGY-HEMATOLOGYPC
Entity type:Organization
Organization Name:SOOMCHUNGMDONCOLOGY-HEMATOLOGYPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SOO
Authorized Official - Middle Name:MARN
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-539-6414
Mailing Address - Street 1:12555 GARDEN GROVE BLVD STE 309
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1903
Mailing Address - Country:US
Mailing Address - Phone:714-539-6414
Mailing Address - Fax:714-539-6933
Practice Address - Street 1:12555 GARDEN GROVE BLVD STE 309
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1903
Practice Address - Country:US
Practice Address - Phone:714-539-6414
Practice Address - Fax:714-539-6933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41090207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A410900Medicaid
CA05D0675453OtherCLIA
CA05D0675453OtherCLIA