Healthcare Provider Details

I. General information

NPI: 1831731611
Provider Name (Legal Business Name): KEVIN JAE CHOI, MD, MS A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2019
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 S WESTERN AVE STE 101
LOS ANGELES CA
90006-1014
US

IV. Provider business mailing address

966 S WESTERN AVE STE 101
LOS ANGELES CA
90006-1014
US

V. Phone/Fax

Practice location:
  • Phone: 213-267-2256
  • Fax: 213-463-9131
Mailing address:
  • Phone: 213-267-2566
  • Fax: 213-463-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. KEVIN JAE CHOI
Title or Position: PHYSICIAN
Credential: MD
Phone: 213-267-2256