Healthcare Provider Details

I. General information

NPI: 1538306014
Provider Name (Legal Business Name): SANG YOON OH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-2803
  • Fax:
Mailing address:
  • Phone: 360-736-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD 60082411
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: