Provider Demographics
NPI:1073217444
Name:YOON, JUNG IL
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:IL
Last Name:YOON
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 1:2700 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2576
Mailing Address - Country:US
Mailing Address - Phone:313-494-6873
Mailing Address - Fax:313-494-6834
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6873
Practice Address - Fax:313-494-6834
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901601855390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty