Provider Demographics
NPI:1407267586
Name:HEE SOO JEONG MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HEE SOO JEONG MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:MIRAE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEE SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-387-1541
Mailing Address - Street 1:2675 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2880
Mailing Address - Country:US
Mailing Address - Phone:213-387-1541
Mailing Address - Fax:866-531-4907
Practice Address - Street 1:2675 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2880
Practice Address - Country:US
Practice Address - Phone:213-387-1541
Practice Address - Fax:866-531-4907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA105825OtherPROFESSIONAL LICENSE