Healthcare Provider Details

I. General information

NPI: 1689673840
Provider Name (Legal Business Name): CHENG LONG KUO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 WEST LOMITA BLVD
HARBOR CITY CA
90710
US

IV. Provider business mailing address

1533 WEST LOMITA BLVD
HARBOR CITY CA
90710
US

V. Phone/Fax

Practice location:
  • Phone: 310-539-4398
  • Fax: 310-539-7921
Mailing address:
  • Phone: 310-539-4398
  • Fax: 310-539-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA031619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: