Provider Demographics
NPI:1609398072
Name:NGO, JOHN (BA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NGO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12912 BROOKHURST ST STE 420
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4849
Mailing Address - Country:US
Mailing Address - Phone:714-636-9095
Mailing Address - Fax:
Practice Address - Street 1:12966 EUCLID ST STE 495
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-9209
Practice Address - Country:US
Practice Address - Phone:714-981-5932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
0022752594OtherKAISER
CA92041972D03352Medicaid