Healthcare Provider Details

I. General information

NPI: 1073360079
Provider Name (Legal Business Name): SOOHYUN JOE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE C1010957
LA JOLLA CA
92037-1714
US

IV. Provider business mailing address

8950 VILLA LA JOLLA DR STE C1010957
LA JOLLA CA
92037-1714
US

V. Phone/Fax

Practice location:
  • Phone: 858-249-1680
  • Fax:
Mailing address:
  • Phone: 858-249-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberRPS304
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: