Healthcare Provider Details

I. General information

NPI: 1518145366
Provider Name (Legal Business Name): JESSE KO, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20945 45TH RD FL 1
BAYSIDE NY
11361-3233
US

IV. Provider business mailing address

20945 45TH RD FL 1
BAYSIDE NY
11361-3233
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-7200
  • Fax: 718-224-8727
Mailing address:
  • Phone: 718-423-7200
  • Fax: 718-224-8727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number213571
License Number StateNY

VIII. Authorized Official

Name: DR. JESSE KO
Title or Position: OWNER
Credential: M.D.
Phone: 718-423-7200