Provider Demographics
NPI:1801989736
Name:KANG, JA GU (MD)
Entity type:Individual
Prefix:DR
First Name:JA
Middle Name:GU
Last Name:KANG
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 1:60 07 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:718-478-7772
Mailing Address - Fax:718-429-5245
Practice Address - Street 1:60 07 43RD AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-478-7772
Practice Address - Fax:718-429-5245
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
59862Medicare ID - Type Unspecified
B88706Medicare UPIN