Healthcare Provider Details

I. General information

NPI: 1164631966
Provider Name (Legal Business Name): JACK I. KUO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11863 DARLINGTON AVE UNIT G1
LOS ANGELES CA
90049-7223
US

IV. Provider business mailing address

11863 DARLINGTON AVE UNIT G1
LOS ANGELES CA
90049-7223
US

V. Phone/Fax

Practice location:
  • Phone: 310-696-1288
  • Fax:
Mailing address:
  • Phone: 310-696-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA77421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: