Healthcare Provider Details

I. General information

NPI: 1669634648
Provider Name (Legal Business Name): STEPHEN CHII-MING KO MD MA MPH MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL RD
OAK BLUFFS MA
02557-1406
US

IV. Provider business mailing address

525 EAST 68TH STREET HT 510
NEW YORK NY
10021
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-0410
  • Fax:
Mailing address:
  • Phone: 212-746-3320
  • Fax: 212-746-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number238993
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number238993
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: