Healthcare Provider Details

I. General information

NPI: 1194122689
Provider Name (Legal Business Name): YOUNG-GWANG JEONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-3851
US

IV. Provider business mailing address

60 BROADWAY APT 3S
BROOKLYN NY
11249-8642
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6211
  • Fax:
Mailing address:
  • Phone: 646-943-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number297198
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number297198
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number297198
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: