Provider Demographics
NPI:1073076568
Name:CHOI, BONGYONG
Entity Type:Individual
Prefix:
First Name:BONGYONG
Middle Name:
Last Name:CHOI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 CLOVERDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2742
Mailing Address - Country:US
Mailing Address - Phone:909-567-3870
Mailing Address - Fax:718-691-4366
Practice Address - Street 1:24825 NORTHERN BLVD STE 2B
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1280
Practice Address - Country:US
Practice Address - Phone:347-235-4742
Practice Address - Fax:718-691-4366
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY571812731OtherDRIVER LICENSE