Provider Demographics
NPI:1518120955
Name:YOO, MYUNG JAE (MD)
Entity Type:Individual
Prefix:DR
First Name:MYUNG
Middle Name:JAE
Last Name:YOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3473 SATELLITE BLVD
Mailing Address - Street 2:120 N
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8690
Mailing Address - Country:US
Mailing Address - Phone:770-559-8385
Mailing Address - Fax:770-674-7367
Practice Address - Street 1:3473 SATELLITE BLVD
Practice Address - Street 2:120 N
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8690
Practice Address - Country:US
Practice Address - Phone:770-559-8385
Practice Address - Fax:770-674-7367
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7275208100000X
GA707982081P2900X
VA0101257597208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14855Medicaid
9263478OtherDAKOTACARE
SDS102602Medicare PIN