Provider Demographics
NPI:1699868224
Name:HAN, KYUNG MO (MD)
Entity type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:MO
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 W OLYMPIC BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2800
Mailing Address - Country:US
Mailing Address - Phone:213-387-7800
Mailing Address - Fax:213-387-0357
Practice Address - Street 1:2655 W OLYMPIC BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2800
Practice Address - Country:US
Practice Address - Phone:213-387-7800
Practice Address - Fax:213-387-0357
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA045923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA045923OtherLICENSE NUMBER
CA00A459231Medicaid
CAA045923OtherLICENSE NUMBER
CAA45923Medicare ID - Type UnspecifiedMEDICARE I.D.