Provider Demographics
NPI:1942613369
Name:KO, MIA CHWAN
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:CHWAN
Last Name:KO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E HECTOR ST UNIT 434
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2456
Mailing Address - Country:US
Mailing Address - Phone:646-709-3236
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD YORK RD STE 404
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3046
Practice Address - Country:US
Practice Address - Phone:856-342-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0189062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology