Provider Demographics
NPI:1326116344
Name:KO, JOSAN WAI-TAK (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSAN
Middle Name:WAI-TAK
Last Name:KO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JOSAN
Other - Middle Name:WAI-TAK
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4620 OAK GROVE PKWY N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-4062
Mailing Address - Country:US
Mailing Address - Phone:763-315-0909
Mailing Address - Fax:
Practice Address - Street 1:4620 OAK GROVE PKWY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-4062
Practice Address - Country:US
Practice Address - Phone:763-315-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2869152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1649348681Medicaid
MN22-02901OtherMEDICA
MNJ52607OtherDAVIS VISION
MN166K5KOOtherBCBSM
MNMN02869OtherVBA
MN19982OtherNVA
MN181414OtherUCARE MINNESOTA
MN26833OtherSPECTERA
MN697670100Medicaid
MN244301040082OtherPREFERRED ONE
MN9529921700OtherPATIENT CHOICE
MN19982OtherNVA
MN697670100Medicaid