Healthcare Provider Details

I. General information

NPI: 1528972833
Provider Name (Legal Business Name): JEFFREY OH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2718 W ROSCOE ST
CHICAGO IL
60618-5910
US

IV. Provider business mailing address

34781 DORADO CMN
FREMONT CA
94555-2727
US

V. Phone/Fax

Practice location:
  • Phone: 773-961-3000
  • Fax:
Mailing address:
  • Phone: 510-896-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number69101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: