Provider Demographics
NPI:1114914157
Name:KANG, MARK M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:KANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:MYUNGSIK
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2750 SYCAMORE DR
Mailing Address - Street 2:STE 209
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1502
Mailing Address - Country:US
Mailing Address - Phone:805-527-8027
Mailing Address - Fax:805-584-3809
Practice Address - Street 1:2750 SYCAMORE DR
Practice Address - Street 2:STE 209
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1502
Practice Address - Country:US
Practice Address - Phone:805-527-8027
Practice Address - Fax:805-584-3809
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32105208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A321050Medicaid
CA00A321050Medicaid
CAA32105AMedicare ID - Type Unspecified