Provider Demographics
NPI:1689803652
Name:DONG, JAE WOOK (MD)
Entity Type:Individual
Prefix:DR
First Name:JAE WOOK
Middle Name:
Last Name:DONG
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 1:1355 PEACHTREE ST NE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3276
Mailing Address - Country:US
Mailing Address - Phone:678-223-7774
Mailing Address - Fax:678-223-7799
Practice Address - Street 1:4275 JOHNS CREEK PKWY STE A
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:678-475-1606
Practice Address - Fax:678-475-1615
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055845207R00000X
IA40328207R00000X
GA080202207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003204609MMedicaid