Provider Demographics
NPI:1073603171
Name:JANG, JONATHAN RYOHWAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RYOHWAN
Last Name:JANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W LAKEVIEW DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-7960
Mailing Address - Country:US
Mailing Address - Phone:601-444-4798
Mailing Address - Fax:601-444-5127
Practice Address - Street 1:2 W LAKEVIEW DR
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-7960
Practice Address - Country:US
Practice Address - Phone:601-444-4798
Practice Address - Fax:601-444-5127
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126888Medicaid
MS00126888Medicaid