Provider Demographics
NPI:1477736650
Name:DAE-WOOK KANG, M.D. PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DAE-WOOK KANG, M.D. PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAE-WOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-280-5500
Mailing Address - Street 1:2000 W HEDDING ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1426
Mailing Address - Country:US
Mailing Address - Phone:408-280-5500
Mailing Address - Fax:408-275-8311
Practice Address - Street 1:2000 W. HEDDING ST.
Practice Address - Street 2:SUITE 10
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1426
Practice Address - Country:US
Practice Address - Phone:408-280-5500
Practice Address - Fax:408-275-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79486261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G794860Medicaid
CAG11146Medicare UPIN
CA00G794860Medicare PIN