Healthcare Provider Details

I. General information

NPI: 1639519663
Provider Name (Legal Business Name): JUNGWOO HAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MIDDLETOWN RD STE 11
PEARL RIVER NY
10965-1296
US

IV. Provider business mailing address

300 N MIDDLETOWN RD STE 11
PEARL RIVER NY
10965-1296
US

V. Phone/Fax

Practice location:
  • Phone: 845-735-8440
  • Fax: 845-735-8445
Mailing address:
  • Phone: 845-735-8440
  • Fax: 845-735-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00328500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006740
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: