Healthcare Provider Details

I. General information

NPI: 1306208509
Provider Name (Legal Business Name): CHARLES C KO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHARLES C KO MD

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 BLACK HORSE PIKE
EGG HARBOR TOWNSHIP NJ
08234-4509
US

IV. Provider business mailing address

1125 SANSOM ST APT 611
PHILADELPHIA PA
19107-4866
US

V. Phone/Fax

Practice location:
  • Phone: 856-459-3855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD473648
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: