Provider Demographics
NPI:1093814675
Name:YANG, JAE K (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:K
Last Name:YANG
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 1:103 NORTH OAK ST.
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-624-3368
Mailing Address - Fax:
Practice Address - Street 1:103 NORTH OAK ST.
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-624-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-053690207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45112Medicare UPIN