Provider Demographics
NPI:1255834974
Name:SON, JAE HUN
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:HUN
Last Name:SON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 N COLUMBUS ST STE 260
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8100
Mailing Address - Country:US
Mailing Address - Phone:740-687-8397
Mailing Address - Fax:740-654-4103
Practice Address - Street 1:1550 SHERIDAN DR STE 203
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1380
Practice Address - Country:US
Practice Address - Phone:740-687-8397
Practice Address - Fax:740-654-4103
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program