Provider Demographics
NPI:1083726905
Name:KOH, SANDY SOONCHUNG (MD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:SOONCHUNG
Last Name:KOH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOONCHUNG
Other - Middle Name:S
Other - Last Name:KOH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3419 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3103
Mailing Address - Country:US
Mailing Address - Phone:626-350-2197
Mailing Address - Fax:
Practice Address - Street 1:2727 PECK RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2434
Practice Address - Country:US
Practice Address - Phone:626-350-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A345830208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A345830Medicaid