Basic Information
| Provider Information | |||||||||
| NPI: | 1689803652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONG | ||||||||
| FirstName: | JAE WOOK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1355 PEACHTREE ST NE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303093276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782237774 | ||||||||
| FaxNumber: | 6782237799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4275 JOHNS CREEK PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784751606 | ||||||||
| FaxNumber: | 6784751615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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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 | 207R00000X | 125055845 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 40328 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 080202 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003204609M | 05 | GA | MEDICAID |