=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114182219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON SZEPOK KONG DO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2008
-----------------------------------------------------
Last Update Date | 12/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 MAIN ST 309
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-886-2906
-----------------------------------------------------
Fax | 718-301-1775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3901 MAIN ST 309
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-886-2906
-----------------------------------------------------
Fax | 718-301-1775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON SZEPOK KONG
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 718-551-1401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 246399
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------