Healthcare Provider Details

I. General information

NPI: 1922410364
Provider Name (Legal Business Name): VINCENT WONSUN KANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S MAIN ST STE 2
DAYTON OH
45409-2643
US

IV. Provider business mailing address

1520 S MAIN ST STE 2
DAYTON OH
45409-2643
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-5815
  • Fax: 937-461-2896
Mailing address:
  • Phone: 937-461-5815
  • Fax: 937-461-2896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.013276
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number34.013276
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: