Healthcare Provider Details

I. General information

NPI: 1770549289
Provider Name (Legal Business Name): JESSE KO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA 068417
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number213571-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: