Healthcare Provider Details

I. General information

NPI: 1518120955
Provider Name (Legal Business Name): MYUNG JAE YOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3473 SATELLITE BLVD 120 N
DULUTH GA
30096-8690
US

IV. Provider business mailing address

3473 SATELLITE BLVD 120 N
DULUTH GA
30096-8690
US

V. Phone/Fax

Practice location:
  • Phone: 770-559-8385
  • Fax: 770-674-7367
Mailing address:
  • Phone: 770-559-8385
  • Fax: 770-674-7367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number7275
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number70798
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101257597
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: