Basic Information
| Provider Information | |||||||||
| NPI: | 1639359342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEO | ||||||||
| FirstName: | JEONG | ||||||||
| MiddleName: | SOK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2438 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317762438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919009 | ||||||||
| FaxNumber: | 2298901282 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 HOSPITAL PARK | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919009 | ||||||||
| FaxNumber: | 2298901282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 208M00000X | 065307 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 65307 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003109900E | 05 | GA | MEDICAID | 202I119252 | 01 | GA | MEDICARE PTAN | OTHER | 003109900D | 05 | GA | MEDICAID |