Healthcare Provider Details

I. General information

NPI: 1790996890
Provider Name (Legal Business Name): WYNN HUGH KAO M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 E EMPIRE ST STE E & F
BLOOMINGTON IL
61704-5402
US

IV. Provider business mailing address

3024 E EMPIRE ST STE E&F
BLOOMINGTON IL
61704-5402
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-3376
  • Fax: 309-452-3376
Mailing address:
  • Phone: 309-451-3376
  • Fax: 309-452-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.143480
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: