Basic Information
| Provider Information | |||||||||
| NPI: | 1710510540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOO-BUNYARD | ||||||||
| FirstName: | MIJEONG | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5942 FLOREY RD | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210761384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672127773 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1153 MD-3N | ||||||||
| Address2: | SUITE 35 | ||||||||
| City: | GAMBRILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2020 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 27816 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.