Provider Demographics
NPI:1023126869
Name:RO, KYUNG KOOK (MD)
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:KOOK
Last Name:RO
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:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-0788
Mailing Address - Country:US
Mailing Address - Phone:714-636-0343
Mailing Address - Fax:714-636-0391
Practice Address - Street 1:12601 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-636-0342
Practice Address - Fax:714-636-0391
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51432207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C514320Medicaid
CAC51432Medicare PIN
CAWC51432AMedicare PIN
CA00C514320Medicaid