Provider Demographics
NPI:1508932989
Name:IM, WON GI (MD)
Entity Type:Individual
Prefix:
First Name:WON GI
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BROADWAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:631-789-7429
Mailing Address - Fax:631-789-8571
Practice Address - Street 1:221 BROADWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-789-7429
Practice Address - Fax:631-789-8571
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1077722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00190092Medicaid
B16549Medicare UPIN
NY00190092Medicaid