Provider Demographics
NPI:1164577706
Name:KANG, SOO WOONG
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:WOONG
Last Name:KANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6714 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-3410
Mailing Address - Country:US
Mailing Address - Phone:714-572-6778
Mailing Address - Fax:714-752-6809
Practice Address - Street 1:6714 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-3410
Practice Address - Country:US
Practice Address - Phone:147-526-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666300Medicaid
H13099Medicare UPIN
CA00A666300Medicaid
CAW21098Medicare PIN