Healthcare Provider Details

I. General information

NPI: 1942379052
Provider Name (Legal Business Name): DR. JAE RYU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133-47 SANFORD AVENUE
FLUSHING NY
11355
US

IV. Provider business mailing address

80 MARCUS DRIVE PROVIDER ENROLLMENT
MELVILLE NY
11747
US

V. Phone/Fax

Practice location:
  • Phone: 718-359-1507
  • Fax:
Mailing address:
  • Phone: 631-391-7887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number217530
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: