Provider Demographics
NPI:1720083322
Name:KO, KYONG YOL (MD)
Entity Type:Individual
Prefix:DR
First Name:KYONG
Middle Name:YOL
Last Name:KO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:101 GREEN PASTURE CT
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021
Mailing Address - Country:US
Mailing Address - Phone:505-824-5007
Mailing Address - Fax:505-825-0322
Practice Address - Street 1:545 S. COUNTY LINE DR.
Practice Address - Street 2:SPACE A
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7809
Practice Address - Country:US
Practice Address - Phone:505-824-5007
Practice Address - Fax:505-824-0322
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM2003-0543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40725391Medicaid
NMI05238Medicare UPIN