=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518120955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYUNG JAE YOO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2008
-----------------------------------------------------
Last Update Date | 04/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3473 SATELLITE BLVD 120 N
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-8690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-559-8385
-----------------------------------------------------
Fax | 770-674-7367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3473 SATELLITE BLVD 120 N
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-8690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-559-8385
-----------------------------------------------------
Fax | 770-674-7367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 7275
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 70798
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 0101257597
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------