Basic Information
| Provider Information | |||||||||
| NPI: | 1205060290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KO | ||||||||
| FirstName: | FANG | ||||||||
| MiddleName: | SARAH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 FLEISCHMANN RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508786161 | ||||||||
| FaxNumber: | 8506560200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 FLEISCHMANN RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508786161 | ||||||||
| FaxNumber: | 8506560200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME125176 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 018721300 | 05 | FL | MEDICAID |