Healthcare Provider Details

I. General information

NPI: 1386894566
Provider Name (Legal Business Name): JACK S KAO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 W OLYMPIC BLVD
LOS ANGELES CA
90036-4671
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 310-657-5900
  • Fax:
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA69438
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA69438
License Number StateCA

VIII. Authorized Official

Name: JACK S KAO
Title or Position: PRESIDENT/SOLE OWNER
Credential: M.D.
Phone: 818-888-7815