Provider Demographics
NPI:1083851687
Name:KO, PAN SOK (MD)
Entity Type:Individual
Prefix:DR
First Name:PAN
Middle Name:SOK
Last Name:KO
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 1:400 SYLVAN AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2729
Mailing Address - Country:US
Mailing Address - Phone:201-408-5314
Mailing Address - Fax:201-408-4431
Practice Address - Street 1:400 SYLVAN AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2729
Practice Address - Country:US
Practice Address - Phone:201-408-5314
Practice Address - Fax:201-408-4431
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08411400207RI0200X, 207RI0200X
PAMD435218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0430480Medicaid
NJ0190756Medicaid
NJ0430480Medicaid
NJ148588ZC8AMedicare PIN
NJ0190756Medicaid
NJ148588Medicare PIN