Healthcare Provider Details

I. General information

NPI: 1023126869
Provider Name (Legal Business Name): KYUNG KOOK RO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12601 GARDEN GROVE BLVD
GARDEN GROVE CA
92843
US

IV. Provider business mailing address

PO BOX 788
HEMET CA
92546-0788
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-0342
  • Fax: 714-636-0391
Mailing address:
  • Phone: 714-636-0343
  • Fax: 714-636-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC51432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: