Provider Demographics
NPI:1508038415
Name:KANG, SOO YEON KELLY (MD,)
Entity Type:Individual
Prefix:DR
First Name:SOO YEON
Middle Name:KELLY
Last Name:KANG
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:DR
Other - First Name:SOO YEON
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11303 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6003
Mailing Address - Country:US
Mailing Address - Phone:310-301-7396
Mailing Address - Fax:
Practice Address - Street 1:11303 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:310-301-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1092392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508038415Medicaid
CAFE163YMedicare PIN