Provider Demographics
NPI:1942243449
Name:NGO, PHONG XUAN (MD)
Entity type:Individual
Prefix:DR
First Name:PHONG
Middle Name:XUAN
Last Name:NGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 GRAND OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3611
Mailing Address - Country:US
Mailing Address - Phone:626-437-1340
Mailing Address - Fax:
Practice Address - Street 1:525 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1202
Practice Address - Country:US
Practice Address - Phone:626-307-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD126280207P00000X, 207R00000X
CAG80943207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612953Medicaid
CA00G809430Medicaid
CAWG80943EMedicare PIN
CAWG809743Medicare PIN
CAWG80943DMedicare PIN
ORR150837Medicare PIN
CAG44699Medicare UPIN
OR500612953Medicaid