Healthcare Provider Details

I. General information

NPI: 1932193976
Provider Name (Legal Business Name): MYUNG JA KANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MYUNG JA KIM

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 DELMAR BOULEVARD
SAINT LOUIS MO
63112-0000
US

IV. Provider business mailing address

5535 DELMAR BLVD
SAINT LOUIS MO
63112-3005
US

V. Phone/Fax

Practice location:
  • Phone: 314-879-6363
  • Fax: 314-879-6372
Mailing address:
  • Phone: 314-879-6363
  • Fax: 314-879-6372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR7005
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: