MEDICARE: HEESOO JEONG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	41808	AZ
3	207R00000X	Internal Medicine Physician	105825	CA

General Provider Information

NPI Number	:	1174701429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEESOO JEONG M.D.

Provider Business Mailing Address
First Line	:	2675 W OLYMPIC BLVD
Second Line	:	#202
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2880
Country	:	US
Telephone Number	:	213-387-1541
Fax Number	:

Provider Business Practice Location Address
First Line	:	2675 W OLYMPIC BLVD
Second Line	:	#202
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2880
Country	:	US
Telephone Number	:	213-387-1541
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2008
Last Update Date	:	06/22/2014

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Directions to “ HEESOO JEONG M.D.” Practice Location

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