Healthcare Provider Details

I. General information

NPI: 1417061300
Provider Name (Legal Business Name): KIJEON YOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 ISLAND ST
PLAINVIEW NY
11803-4617
US

IV. Provider business mailing address

998 CROOKED HILL RD
WEST BRENTWOOD NY
11717-1019
US

V. Phone/Fax

Practice location:
  • Phone: 631-487-5241
  • Fax:
Mailing address:
  • Phone: 631-761-3535
  • Fax: 631-761-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number239188
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: