Provider Demographics
NPI:1083782783
Name:CHOI, BONG H (MD)
Entity Type:Individual
Prefix:
First Name:BONG
Middle Name:H
Last Name:CHOI
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:PO BOX 1923
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-1923
Mailing Address - Country:US
Mailing Address - Phone:908-490-0036
Mailing Address - Fax:908-490-0067
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:908-490-0036
Practice Address - Fax:908-490-0067
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02728700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0333107Medicaid
NJ440695B8TMedicare PIN
NJ0333107Medicaid