Healthcare Provider Details

I. General information

NPI: 1902367642
Provider Name (Legal Business Name): SEBASTIAN KO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date: 11/04/2019
Reactivation Date: 11/27/2019

III. Provider practice location address

701 E EL CAMINO REAL
MOUNTAIN VIEW CA
94040-2833
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 650-934-7111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.148139
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC199717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: