Provider Demographics
NPI:1043396310
Name:HAN, SANG JO (MD)
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:JO
Last Name:HAN
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 1:473 W ARMY TRAIL ROAD
Mailing Address - Street 2:# 102
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108
Mailing Address - Country:US
Mailing Address - Phone:630-529-6969
Mailing Address - Fax:630-529-7497
Practice Address - Street 1:473 W ARMY TRAIL ROAD
Practice Address - Street 2:# 102
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108
Practice Address - Country:US
Practice Address - Phone:630-529-6969
Practice Address - Fax:630-529-7497
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061812Medicaid
C42815Medicare UPIN