Basic Information
| Provider Information | |||||||||
| NPI: | 1003802380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUANG | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | 7038978763 | ||||||||
| Practice Location | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | 7038978763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101235911 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 010102138 | 05 | VA | MEDICAID |