Provider Demographics
NPI:1811576358
Name:KANG, LUKE CHANG-DAE (MD)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:CHANG-DAE
Last Name:KANG
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 1:260 HOSPITAL DR STE 209
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4568
Mailing Address - Country:US
Mailing Address - Phone:707-463-7483
Mailing Address - Fax:
Practice Address - Street 1:260 HOSPITAL DR STE 209
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4568
Practice Address - Country:US
Practice Address - Phone:707-463-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUTLL-2024-003207Q00000X
390200000X
CA192721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program