MEDICARE: SANDY S KOH M.D., INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A34583	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134364748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDY S KOH M.D., INC

Provider Business Mailing Address
First Line	:	3419 TYLER AVE
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91731-3103
Country	:	US
Telephone Number	:	626-350-2197
Fax Number	:	626-350-2111

Provider Business Practice Location Address
First Line	:	2727 PECK RD
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91733-2434
Country	:	US
Telephone Number	:	626-350-2196
Fax Number	:	626-350-4030

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SANDY S KOH
Credential	:	M.D.
Telephone Number	:	626-350-2196

Provider Enumeration Date	:	12/10/2008
Last Update Date	:	12/10/2008

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