Healthcare Provider Details

I. General information

NPI: 1982090692
Provider Name (Legal Business Name): MICKEY J M KUO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN MYLES KUO

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BG 10 RM 13N268 10 CENTER DR
BETHESDA MD
20814
US

IV. Provider business mailing address

10 CENTER DR
BETHESDA MD
20892-0004
US

V. Phone/Fax

Practice location:
  • Phone: 301-594-7487
  • Fax:
Mailing address:
  • Phone: 301-594-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberD0087738
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036172200
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125067676
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: