Basic Information
| Provider Information | |||||||||
| NPI: | 1710415955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KER YONG JUSTINE KOH MD A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28128 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937298128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594360871 | ||||||||
| FaxNumber: | 5594365221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095763514 | ||||||||
| FaxNumber: | 5594365221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2017 | ||||||||
| LastUpdateDate: | 06/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | KOH | ||||||||
| AuthorizedOfficialFirstName: | KER YONG | ||||||||
| AuthorizedOfficialMiddleName: | JUSTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5594360871 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C140941 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1083775787 | 01 | NPI | OTHER |