Provider Demographics
NPI:1598739484
Name:KOO, YEONSUK CHOI (MD)
Entity Type:Individual
Prefix:
First Name:YEONSUK
Middle Name:CHOI
Last Name:KOO
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 1:909 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3742
Mailing Address - Country:US
Mailing Address - Phone:217-431-8133
Mailing Address - Fax:217-431-8134
Practice Address - Street 1:909 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3742
Practice Address - Country:US
Practice Address - Phone:217-431-8133
Practice Address - Fax:217-431-8134
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2009-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058658208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058658Medicaid