Provider Demographics
NPI:1164428199
Name:OH, KONG T (MD)
Entity Type:Individual
Prefix:
First Name:KONG
Middle Name:T
Last Name:OH
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 1:8110 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6243
Mailing Address - Country:US
Mailing Address - Phone:330-758-0900
Mailing Address - Fax:
Practice Address - Street 1:8110 MARKET ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-6243
Practice Address - Country:US
Practice Address - Phone:330-758-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-2367-O207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0452611Medicare ID - Type Unspecified
B77532Medicare UPIN