Provider Demographics
NPI:1144887597
Name:JI, BONGHAK (PT DPT OCS CSCS)
Entity type:Individual
Prefix:DR
First Name:BONGHAK
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:PT DPT OCS CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14021 32ND AVE APT 6CN
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-2640
Mailing Address - Country:US
Mailing Address - Phone:347-209-3684
Mailing Address - Fax:
Practice Address - Street 1:15007 BAYSIDE AVE FL 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-2432
Practice Address - Country:US
Practice Address - Phone:347-209-3684
Practice Address - Fax:315-570-9902
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035793225100000X
NY2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty