Provider Demographics
NPI:1710510540
Name:JOO-BUNYARD, MIJEONG (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIJEONG
Middle Name:
Last Name:JOO-BUNYARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5942 FLOREY RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1384
Mailing Address - Country:US
Mailing Address - Phone:667-212-7773
Mailing Address - Fax:
Practice Address - Street 1:1153 MD-3N
Practice Address - Street 2:SUITE 35
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist