Provider Demographics
NPI:1437539756
Name:KANG, JUAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:
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 1:12939 BANYAN TOWN DR.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146
Mailing Address - Country:US
Mailing Address - Phone:314-434-1755
Mailing Address - Fax:
Practice Address - Street 1:12939 BANYAN TOWN DR.
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146
Practice Address - Country:US
Practice Address - Phone:314-434-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001001573207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology