Healthcare Provider Details

I. General information

NPI: 1083604219
Provider Name (Legal Business Name): DICKEN SHIU-CHUNG KO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 175
PROVIDENCE RI
02905-3246
US

IV. Provider business mailing address

75 NEWMAN AVE STE 100
RUMFORD RI
02916-3603
US

V. Phone/Fax

Practice location:
  • Phone: 401-421-0710
  • Fax: 401-421-0796
Mailing address:
  • Phone: 401-854-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number042.0012769
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number79821
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: