Provider Demographics
NPI:1508180779
Name:KO, KANG H (SP)
Entity Type:Individual
Prefix:MR
First Name:KANG
Middle Name:H
Last Name:KO
Suffix:
Gender:M
Credentials:SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:62-10 WOODSIDE AVE
Mailing Address - Street 2:SUITE NO. 312
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:718-565-8354
Mailing Address - Fax:718-565-5987
Practice Address - Street 1:6319 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3641
Practice Address - Country:US
Practice Address - Phone:718-429-2140
Practice Address - Fax:718-565-5987
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00542847Medicaid
NY00542847Medicaid