Provider Demographics
NPI:1013960475
Name:KAO, JACK SHIH-CHIEH (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:SHIH-CHIEH
Last Name:KAO
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 1:1155 S GRAND AVE APT 1212
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2789
Mailing Address - Country:US
Mailing Address - Phone:714-309-6697
Mailing Address - Fax:
Practice Address - Street 1:1155 S GRAND AVE APT 1212
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-2789
Practice Address - Country:US
Practice Address - Phone:714-309-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219901207L00000X
CAA69438207R00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC904ZMedicare PIN