Basic Information
| Provider Information | |||||||||
| NPI: | 1366620031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OH | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | HANA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, FAAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
| FaxNumber: | 8604507396 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
| FaxNumber: | 8604507396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD126302 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 63007 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500616890 | 05 | OR | MEDICAID |