Healthcare Provider Details

I. General information

NPI: 1184185035
Provider Name (Legal Business Name): SAMUEL YOUNGSOO JO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL
NEW BRUNSWICK NJ
08901-1928
US

IV. Provider business mailing address

125 PATERSON ST
NEW BRUNSWICK NJ
08901-1962
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-8887
  • Fax:
Mailing address:
  • Phone: 732-235-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA11449500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA11449500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: