Provider Demographics
NPI:1508485269
Name:SEO, JEONG
Entity Type:Individual
Prefix:
First Name:JEONG
Middle Name:
Last Name:SEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163-26 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHIING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:718-353-3988
Mailing Address - Fax:
Practice Address - Street 1:163-26 NORTHERN BLVD
Practice Address - Street 2:FLUSHING
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:718-353-3988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005332171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist