Healthcare Provider Details

I. General information

NPI: 1407851793
Provider Name (Legal Business Name): KIM ONG GOCOCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 INTERNATIONAL DR
GREENVILLE SC
29615-4816
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-987-7000
  • Fax: 864-672-7852
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number15816
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: