MEDICARE: DR. KWOKBUN B SO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	14388	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0071520	OTHER	AZ	BLUE CROSS ID#

General Provider Information

NPI Number	:	1578620142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KWOKBUN B SO MD

Provider Business Mailing Address
First Line	:	2525 E ARIZONA BILTMORE CIR
Second Line	:	#116
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2146
Country	:	US
Telephone Number	:	602-381-0318
Fax Number	:	602-381-0236

Provider Business Practice Location Address
First Line	:	2525 E ARIZONA BILTMORE CIR
Second Line	:	#116
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2146
Country	:	US
Telephone Number	:	602-381-0318
Fax Number	:	602-381-0236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	10/15/2007

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