Basic Information
| Provider Information | |||||||||
| NPI: | 1558538454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANG | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | SOOHYUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2008 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | ME96178 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000484300 | 05 | FL | MEDICAID | 01220205 | 01 | AMERIGROUP | OTHER |