Provider Demographics
NPI:1710415955
Name:KER YONG JUSTINE KOH MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KER YONG JUSTINE KOH MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KER YONG
Authorized Official - Middle Name:JUSTINE
Authorized Official - Last Name:KOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-436-0871
Mailing Address - Street 1:PO BOX 28128
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8128
Mailing Address - Country:US
Mailing Address - Phone:559-436-0871
Mailing Address - Fax:559-436-5221
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-576-3514
Practice Address - Fax:559-436-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC140941207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083775787OtherNPI