Healthcare Provider Details

I. General information

NPI: 1750700209
Provider Name (Legal Business Name): KO KO MAUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7544 MEDICAL DR STE B
GLOUCESTER VA
23061-4299
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-693-9037
  • Fax: 804-693-9486
Mailing address:
  • Phone: 757-316-5800
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101268849
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: