Basic Information
| Provider Information | |||||||||
| NPI: | 1225664253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOGHOYAN | ||||||||
| FirstName: | KENGO | ||||||||
| MiddleName: | ZAVEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1087 BEAUMONT DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951293202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124854000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2020 | ||||||||
| LastUpdateDate: | 03/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.