Provider Demographics
NPI:1669579181
Name:CHY-KOA, LETICIA K (MD)
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:K
Last Name:CHY-KOA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 W. GLEN PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-3703
Mailing Address - Country:US
Mailing Address - Phone:219-924-5004
Mailing Address - Fax:219-924-5358
Practice Address - Street 1:1951 W. GLEN PARK AVENUE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-3703
Practice Address - Country:US
Practice Address - Phone:219-924-5004
Practice Address - Fax:219-924-5358
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100148120AMedicaid
IN100148120AMedicaid
IND95531Medicare UPIN