Basic Information
| Provider Information | |||||||||
| NPI: | 1972780930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OH | ||||||||
| FirstName: | JEONG | ||||||||
| MiddleName: | EUN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 GROVE BEACH RD N | ||||||||
| Address2: | BLDG1, UNIT A | ||||||||
| City: | WESTBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064981656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606643553 | ||||||||
| FaxNumber: | 8603588656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 05/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 046567 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008001633 | 05 | CT | MEDICAID |