Provider Demographics
NPI:1336375450
Name:KO, SU MIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SU MIN
Middle Name:
Last Name:KO
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 1:11166 FAIRFAX BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5017
Mailing Address - Country:US
Mailing Address - Phone:703-277-3360
Mailing Address - Fax:703-277-3370
Practice Address - Street 1:11166 FAIRFAX BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5017
Practice Address - Country:US
Practice Address - Phone:703-277-3360
Practice Address - Fax:703-277-3370
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250991208VP0014X, 2081P2900X
MO2009001606208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9496409OtherAETNA
MO98246OtherHCUSA
MO2009001606OtherMEDICAL LICENSE
MO000000640716OtherBCBS
MO1336375450Medicaid
MO1466660007Medicare PIN
MO146640006Medicare PIN
MO2009001606OtherMEDICAL LICENSE
MOMA2027004Medicare PIN
MO1336375450Medicaid
MOMA2028004Medicare PIN
MO000000640716OtherBCBS
MO137740007Medicare PIN
MOMA1510007Medicare PIN
MOMA11420007Medicare PIN