Healthcare Provider Details

I. General information

NPI: 1043385529
Provider Name (Legal Business Name): SANG WON DACRI-KIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 TAMARACK RD.
NEWARK OH
43055
US

IV. Provider business mailing address

1970 TAMARACK RD.
NEWARK OH
43055
US

V. Phone/Fax

Practice location:
  • Phone: 740-344-2452
  • Fax: 740-522-7305
Mailing address:
  • Phone: 740-344-2452
  • Fax: 740-522-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34006602
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number34006602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: