Healthcare Provider Details

I. General information

NPI: 1154559037
Provider Name (Legal Business Name): RAPHAEL JAEWON YOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDREN'S WAY
SAN DIEGO CA
92132-5502
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-8863
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA10636200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC194824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: