Provider Demographics
NPI:1841243177
Name:KANG, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PUNCHBOWL ST
Mailing Address - Street 2:QEC CLINIC
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2421
Mailing Address - Country:US
Mailing Address - Phone:808-691-4970
Mailing Address - Fax:808-691-4614
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:QEC CLINIC
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2421
Practice Address - Country:US
Practice Address - Phone:808-691-4970
Practice Address - Fax:808-691-4614
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13439174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI570045-03Medicaid
HI570045-03Medicaid