Healthcare Provider Details

I. General information

NPI: 1619464773
Provider Name (Legal Business Name): SUNG WOO KOH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12675 LA MIRADA BLVD STE 220
LA MIRADA CA
90638-2235
US

IV. Provider business mailing address

12675 LA MIRADA BLVD STE 220
LA MIRADA CA
90638-2235
US

V. Phone/Fax

Practice location:
  • Phone: 562-967-2273
  • Fax:
Mailing address:
  • Phone: 562-967-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA164034
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: