Provider Demographics
NPI:1043392426
Name:YOON, IN T (MD)
Entity Type:Individual
Prefix:DR
First Name:IN
Middle Name:T
Last Name:YOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2210
Mailing Address - Country:US
Mailing Address - Phone:765-473-5567
Mailing Address - Fax:
Practice Address - Street 1:29 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2210
Practice Address - Country:US
Practice Address - Phone:765-473-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030026208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100179330AMedicaid
INB29153Medicare UPIN
IN530890Medicare ID - Type Unspecified