Provider Demographics
NPI:1467624197
Name:KO, LAAM (DO)
Entity Type:Individual
Prefix:DR
First Name:LAAM
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-6053
Mailing Address - Country:US
Mailing Address - Phone:414-744-6589
Mailing Address - Fax:414-747-8848
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-744-6589
Practice Address - Fax:414-747-8848
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017757208600000X
WI65212208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467624197Medicaid
WI1467624197Medicaid