Healthcare Provider Details

I. General information

NPI: 1639359342
Provider Name (Legal Business Name): JEONG SOK SEO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HOSPITAL PARK
MOULTRIE GA
31768-6700
US

IV. Provider business mailing address

PO BOX 2438
MOULTRIE GA
31776-2438
US

V. Phone/Fax

Practice location:
  • Phone: 229-891-9009
  • Fax: 229-890-1282
Mailing address:
  • Phone: 229-891-9009
  • Fax: 229-890-1282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number65307
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number065307
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: