Provider Demographics
NPI:1336296722
Name:K. KWANG SOO, M.D., S.C.
Entity Type:Organization
Organization Name:K. KWANG SOO, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAM
Authorized Official - Middle Name:KWANG
Authorized Official - Last Name:SOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-964-6077
Mailing Address - Street 1:PO BOX 170526
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8046
Mailing Address - Country:US
Mailing Address - Phone:414-228-8300
Mailing Address - Fax:414-228-6303
Practice Address - Street 1:2691 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-3838
Practice Address - Country:US
Practice Address - Phone:414-228-8300
Practice Address - Fax:414-228-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19331261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI301 529 00Medicaid
D33591Medicare UPIN