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General NPI Number Information
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NPI Number | 1093282394
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Entity Type | Individual
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Provider Name | WONTAE YOO OD 60906377
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Gender | Male
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Dates
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Enumeration Date | 10/25/2018
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Last Update Date | 10/27/2018
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Provider Practice Location Address
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Address Line | 1810 S 320TH ST STE A
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City | FEDERAL WAY
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State | WA
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Zip | 98003-5639
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Country | US
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Telephone | 812-327-7807
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Fax |
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Provider Business Mailing Address
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Address Line | 430 S DUNN ST APT 209
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City | BLOOMINGTON
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State | IN
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Zip | 47401-4877
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Country | US
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Telephone | 812-327-7807
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 60906377
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License Number State | WA
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