Healthcare Provider Details

I. General information

NPI: 1881023257
Provider Name (Legal Business Name): KSB GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CREEK RD SUITE 380
IRVINE CA
92604-4791
US

IV. Provider business mailing address

33 CREEK RD SUITE 380
IRVINE CA
92604-4791
US

V. Phone/Fax

Practice location:
  • Phone: 949-517-8669
  • Fax:
Mailing address:
  • Phone: 949-517-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA101486
License Number StateCA

VIII. Authorized Official

Name: KONG PENG YAP
Title or Position: OWNER
Credential: M.D.
Phone: 949-517-8669