Provider Demographics
NPI:1639359342
Name:SEO, JEONG SOK (MD)
Entity Type:Individual
Prefix:
First Name:JEONG
Middle Name:SOK
Last Name:SEO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2438
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2438
Mailing Address - Country:US
Mailing Address - Phone:229-891-9009
Mailing Address - Fax:229-890-1282
Practice Address - Street 1:6 HOSPITAL PARK
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6700
Practice Address - Country:US
Practice Address - Phone:229-891-9009
Practice Address - Fax:229-890-1282
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA065307208M00000X
GA65307207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109900EMedicaid
GA202I119252OtherMEDICARE PTAN
GA003109900DMedicaid