Provider Demographics
NPI:1184688574
Name:MAH, SANGWOO (DC)
Entity Type:Individual
Prefix:DR
First Name:SANGWOO
Middle Name:
Last Name:MAH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15419 NORTHERN BLVD # 2F-5
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5029
Mailing Address - Country:US
Mailing Address - Phone:718-746-4919
Mailing Address - Fax:718-746-4920
Practice Address - Street 1:15001 NORTHERN BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3846
Practice Address - Country:US
Practice Address - Phone:718-746-4919
Practice Address - Fax:718-746-4920
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009835-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U82792Medicare UPIN
04309Medicare ID - Type Unspecified