Provider Demographics
NPI:1376731208
Name:YI, EUN JUNG (MD)
Entity Type:Individual
Prefix:
First Name:EUN
Middle Name:JUNG
Last Name:YI
Suffix:
Gender:F
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:PO BOX 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0030
Mailing Address - Country:US
Mailing Address - Phone:360-696-5022
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:2312 NE 129TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3236
Practice Address - Country:US
Practice Address - Phone:360-696-5022
Practice Address - Fax:360-666-0466
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153969207LP2900X, 207L00000X
WAMD60306086207LP2900X
AKMED T 8395207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500651332Medicaid
617287700OtherUS DEPT OF L&I - ASC
WA1376731208Medicaid
WA500049OtherCHPW
P01146797OtherRR MEDICARE
WA0307166OtherWA DEPT OF L&I
3959280OtherCIGNA
WA1376731208Medicaid