Provider Demographics
NPI:1811096936
Name:KO, SUNG-TAO (MD)
Entity type:Individual
Prefix:DR
First Name:SUNG-TAO
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 1:130 S MAIN ST STE 306
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2670
Mailing Address - Country:US
Mailing Address - Phone:630-620-6040
Mailing Address - Fax:630-620-6143
Practice Address - Street 1:130 S MAIN ST STE 306
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2670
Practice Address - Country:US
Practice Address - Phone:630-620-6040
Practice Address - Fax:630-620-6143
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-045253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002215295OtherBLUE CROSS
IL036-045253Medicaid
IL720440Medicare ID - Type Unspecified
IL0002215295OtherBLUE CROSS