Healthcare Provider Details

I. General information

NPI: 1578482329
Provider Name (Legal Business Name): STANLEY G KO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PRATT AVE
BAYSIDE NY
11359-1119
US

IV. Provider business mailing address

17283 HIGHLAND AVE
JAMAICA NY
11432-2896
US

V. Phone/Fax

Practice location:
  • Phone: 718-281-8325
  • Fax:
Mailing address:
  • Phone: 718-281-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number398863
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: