Healthcare Provider Details

I. General information

NPI: 1689986432
Provider Name (Legal Business Name): CHANGJIN SEO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 DITMARS BLVD APT 503
ASTORIA NY
11105-1353
US

IV. Provider business mailing address

4502 DITMARS BLVD APT 503
ASTORIA NY
11105-1353
US

V. Phone/Fax

Practice location:
  • Phone: 917-478-7084
  • Fax:
Mailing address:
  • Phone: 917-478-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101253838
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: