Healthcare Provider Details

I. General information

NPI: 1861011165
Provider Name (Legal Business Name): SEONGHO JOHN JEONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 FAME AVE STE 235
HANOVER PA
17331-1576
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 717-637-0470
  • Fax: 717-316-1626
Mailing address:
  • Phone: 203-688-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD600004200
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD494792
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0103731
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: