Provider Demographics
NPI:1811630916
Name:KO, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13906 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9043
Mailing Address - Country:US
Mailing Address - Phone:562-716-1900
Mailing Address - Fax:
Practice Address - Street 1:1680 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3026
Practice Address - Country:US
Practice Address - Phone:424-338-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A24086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program