Provider Demographics
NPI:1932193976
Name:KANG, MYUNG JA (MD)
Entity Type:Individual
Prefix:DR
First Name:MYUNG
Middle Name:JA
Last Name:KANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MYUNG
Other - Middle Name:JA
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5535 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3005
Mailing Address - Country:US
Mailing Address - Phone:314-879-6363
Mailing Address - Fax:314-879-6372
Practice Address - Street 1:5535 DELMAR BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-0000
Practice Address - Country:US
Practice Address - Phone:314-879-6363
Practice Address - Fax:314-879-6372
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR70052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201417706Medicaid
MO98012931Medicare PIN
MO201417706Medicaid