Healthcare Provider Details

I. General information

NPI: 1649393760
Provider Name (Legal Business Name): JOSEPH K KU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KWONG MIN KU MD

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 170
RIVERSIDE CA
92505-3390
US

IV. Provider business mailing address

4234 RIVERWALK PKWY STE 170
RIVERSIDE CA
92505-3390
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-9204
  • Fax: 951-509-9206
Mailing address:
  • Phone: 951-509-9204
  • Fax: 951-509-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA77679
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5941363-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA77679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: