Provider Demographics
NPI:1154504082
Name:KANG, EDWARD PARK (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PARK
Last Name:KANG
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 1:980 JOHNSON FY RD NE
Mailing Address - Street 2:STE 1040
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1626
Mailing Address - Country:US
Mailing Address - Phone:770-292-3496
Mailing Address - Fax:404-300-2317
Practice Address - Street 1:460 NORTHSIDE CHEROKEE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8017
Practice Address - Country:US
Practice Address - Phone:770-292-3490
Practice Address - Fax:770-721-5615
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN541472086S0129X
GA703092086S0129X
MI4301086626208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135923BMedicaid
GA003135923AMedicaid
GA003135923DMedicaid
GA003135923DMedicaid