Basic Information
Provider Information | |||||||||
NPI: | 1689626103 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOHN | ||||||||
FirstName: | WON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 605043 | ||||||||
Address2: |   | ||||||||
City: | BAYSIDE | ||||||||
State: | NY | ||||||||
PostalCode: | 113605043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7184285333 | ||||||||
FaxNumber: | 7184285332 | ||||||||
Practice Location | |||||||||
Address1: | 21333 39TH AVE STE 248 | ||||||||
Address2: |   | ||||||||
City: | BAYSIDE | ||||||||
State: | NY | ||||||||
PostalCode: | 113612092 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7184285333 | ||||||||
FaxNumber: | 7184285332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 11/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 207025 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0100X | 207025 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 02088860 | 05 | NY |   | MEDICAID |