=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619464773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNG WOO KOH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2018
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12675 LA MIRADA BLVD STE 220
-----------------------------------------------------
City | LA MIRADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90638-2235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-967-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12675 LA MIRADA BLVD STE 220
-----------------------------------------------------
City | LA MIRADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90638-2235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-967-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | A164034
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------