Provider Demographics
NPI:1093282394
Name:YOO, WONTAE (OD 60906377)
Entity Type:Individual
Prefix:DR
First Name:WONTAE
Middle Name:
Last Name:YOO
Suffix:
Gender:M
Credentials:OD 60906377
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 S DUNN ST APT 209
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4877
Mailing Address - Country:US
Mailing Address - Phone:812-327-7807
Mailing Address - Fax:
Practice Address - Street 1:1810 S 320TH ST STE A
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5639
Practice Address - Country:US
Practice Address - Phone:812-327-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60906377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist