Healthcare Provider Details

I. General information

NPI: 1932095783
Provider Name (Legal Business Name): JEESOO DANIEL KANG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

IV. Provider business mailing address

113 SOUTH LOGAN DRIVE
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0641
  • Fax:
Mailing address:
  • Phone: 817-394-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207R00000X
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: