=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942863469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAEYEONG HEO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2019
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 W CARSON ST
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90502-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-222-3897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21249 GREENBROOK DR
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-282-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 61479190
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------