Provider Demographics
NPI:1649393760
Name:KU, JOSEPH K (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:K
Last Name:KU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KWONG
Other - Middle Name:MIN
Other - Last Name:KU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4234 RIVERWALK PKWY STE 170
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3390
Mailing Address - Country:US
Mailing Address - Phone:951-509-9204
Mailing Address - Fax:951-509-9206
Practice Address - Street 1:4234 RIVERWALK PKWY STE 170
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3390
Practice Address - Country:US
Practice Address - Phone:951-509-9204
Practice Address - Fax:951-509-9206
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77679208600000X, 2086S0122X
UT5941363-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265610737OtherORGANIZATION NPI
CA2375538Medicaid