Provider Demographics
NPI:1891997011
Name:KO, IRIS PARK (MD)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:PARK
Last Name:KO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 VIA ARBOLADA
Mailing Address - Street 2:UNIT 223
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-5074
Mailing Address - Country:US
Mailing Address - Phone:714-724-2756
Mailing Address - Fax:
Practice Address - Street 1:75 NEILSON ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-724-4741
Practice Address - Fax:831-763-6069
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010004025207L00000X
NY258895207L00000X
IN01093177A207L00000X
CAA110533207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFK161WMedicare PIN
CAFK161AMedicare PIN
CAP01216596Medicare PIN