Provider Demographics
NPI:1063460301
Name:WHANG, KEVIN TAE IL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TAE IL
Last Name:WHANG
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-577-4444
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA658152085B0100X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A658150Medicaid
CA00A6581517Medicare PIN
CA00A658159Medicare PIN
CAP00649373Medicare PIN
CA00A658157Medicare PIN
CAH63750Medicare UPIN
CA00A6581515Medicare PIN
CA00A658156Medicare PIN
CA00A658150Medicaid
CA00A658153Medicare PIN
CA00A6581511Medicare PIN
CA00A6581514Medicare PIN
CA00A658152Medicare PIN
CA00A658154Medicare PIN
CA00A658158Medicare PIN
CA00A6581510Medicare PIN
CA00A6581512Medicare PIN
CA00A6581516Medicare PIN
CA00A658155Medicare PIN