Healthcare Provider Details

I. General information

NPI: 1003586801
Provider Name (Legal Business Name): SIMON KA CHUN SO, M.D., PROFESSIONAL MEDICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 BARRANCA PKWY STE 245
IRVINE CA
92604-1704
US

IV. Provider business mailing address

4330 BARRANCA PKWY STE 245
IRVINE CA
92604-1704
US

V. Phone/Fax

Practice location:
  • Phone: 949-273-2888
  • Fax: 949-273-2801
Mailing address:
  • Phone: 949-273-2888
  • Fax: 949-273-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SIMON KA CHUN SO
Title or Position: DIRECTOR
Credential: MD
Phone: 949-273-2888