Provider Demographics
NPI:1063500999
Name:JANG, SUNG SOO (MASTER OF PHYSICAL T)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:SOO
Last Name:JANG
Suffix:
Gender:M
Credentials:MASTER OF PHYSICAL T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11275 E MISSISSIPPI AVE
Mailing Address - Street 2:SUITE 2S2
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3263
Mailing Address - Country:US
Mailing Address - Phone:720-859-9105
Mailing Address - Fax:720-859-9106
Practice Address - Street 1:11275 E MISSISSIPPI AVE
Practice Address - Street 2:SUITE 2S2
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3263
Practice Address - Country:US
Practice Address - Phone:720-859-9105
Practice Address - Fax:720-859-9106
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO807102Medicare PIN