DR. SOO YEON KELLY KANG M.D,, NPI 1508038415 — LOS ANGELES (CA)

NPI 1508038415

11+ Years Experience Individual

DR. SOO YEON KELLY KANG M.D,

03/31/2008
PROVIDER ENUMERATION DATE
06/27/2016
LAST UPDATE DATE
1508038415
NPI NUMBER

About DR. SOO YEON KELLY KANG

Sole proprietor? Yes, Entity Type 1 Provider (Individual) is a Sole Proprietor.

DR. SOO YEON KELLY KANG is a provider established in LOS ANGELES, CA. The NPI number of DR. SOO YEON KELLY KANG is 1508038415 and was assigned on 03/31/2008. The practitioners primary taxonomy code is: 390200000X .

Mailing address

  • City: LOS ANGELES
  • State: CA
  • Postal code: 900666003
  • Phone: 3103017396
  • Address: 11303 W WASHINGTON BLVD

Primary Practice Address

  • Region : LOS ANGELES, CA
  • NPI : 1508038415
  • Phone : 3103017396
  • Postalcode : 900666003
  • Address : 11303 W WASHINGTON BLVD

Additional identifiers

  • Identifier: 1508038415
  • Code / Type : 5 - MEDICAID
  • Identifier state : CA

Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Provider taxonomy - Student in an Organized Health Care Education/Training Program

  • Taxonomy code: 390200000X

The taxonomy is not the primary taxonomy.

Taxonomy description: An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.

Healthcare provider taxonomy #2 - Psychiatry & Neurology

  • Taxonomy code: 2084P0800X
  • License number: A109239
  • License state: CA

The taxonomy is the primary taxonomy (there can be only one per NPI record).

Taxonomy description: A Psychiatrist specializes in the prevention, diagnosis, and treatment of mental disorders, emotional disorders, psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, sexual and gender identity disorders and adjustment disorders. Biologic, psychological, and social components of illnesses are explored and understood in treatment of the whole person. Tools used may include diagnostic laboratory tests, prescribed medications, evaluation and treatment of psychological and interpersonal problems with individuals and families, and intervention for coping with stress, crises, and other problems.

Contacts:

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  • DR. SOO YEON KELLY KANG M.D,
  • Address : 11303 W WASHINGTON BLVD
  • Region : LOS ANGELES, CA
  • NPI : 1508038415
  • Phone : 3103017396
  • Postalcode : 900666003

Reference NPI Information. Full replica of the CMS (NPPES) NPI record

Field Name Value
Provider First Line Business Practice Location Address11303 W WASHINGTON BLVD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City NameLOS ANGELES
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State NameCA
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code900666003
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Telephone Number3103017396
The telephone number associated with the location address of the provider being identified.
NPI1508038415
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Healthcare Provider Taxonomy 1390200000X
An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.
Provider Enumeration Date03/31/2008
The date the provider was assigned a unique identifier (assigned an NPI).
Last Updated06/27/2016
The date that a record was last updated or changed.
Entity TypeIndividual
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Provider Organization Name (Legal Business Name)DR. SOO YEON KELLY KANG
Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Line Business Mailing Address11303 W WASHINGTON BLVD
The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Business Mailing Address City NameLOS ANGELES
The City name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address City name".
Provider Business Mailing Address State NameCA
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code900666003
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Telephone Number3103017396
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Healthcare Provider Taxonomy Code #1390200000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1Student in an Organized Health Care Education/Training Program
An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.
Healthcare Provider Primary Taxonomy Switch 1N
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Healthcare Provider Taxonomy Code 22084P0800X
Healthcare Provider Taxonomy 2Psychiatry & Neurology
A Psychiatrist specializes in the prevention, diagnosis, and treatment of mental disorders, emotional disorders, psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, sexual and gender identity disorders and adjustment disorders. Biologic, psychological, and social components of illnesses are explored and understood in treatment of the whole person. Tools used may include diagnostic laboratory tests, prescribed medications, evaluation and treatment of psychological and interpersonal problems with individuals and families, and intervention for coping with stress, crises, and other problems.
Provider License Number 2A109239
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 2CA
Healthcare Provider Primary Taxonomy Switch 2Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Other Provider Identifier 11508038415
Other Provider Identifier #1
Other Provider Identifier Type 15
  • 1 - Other
  • 5 - MEDICAID
Other Provider Identifier State 1CA
Other Provider Identifier State #1
Provider Gender CodeF
  • M - male
  • F - female
Is sole proprietorY
  • X - Not Answered
  • Y - Yes, Entity Type 1 Provider (Individual) is a Sole Proprietor
  • N - No, Entity Type 1 Provider (Individual) is not a Sole Proprietor
X

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