Healthcare Provider Details

I. General information

NPI: 1215413125
Provider Name (Legal Business Name): KEN NAN KUO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 INDIAN TRAIL RD
OAK BROOK IL
60523-2793
US

IV. Provider business mailing address

105 INDIAN TRAIL RD
OAK BROOK IL
60523-2793
US

V. Phone/Fax

Practice location:
  • Phone: 630-205-1853
  • Fax:
Mailing address:
  • Phone: 630-205-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036.045258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: