Provider Demographics
NPI:1780024406
Name:JEON, JIYONG (DPM)
Entity Type:Individual
Prefix:
First Name:JIYONG
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 12TH ST
Mailing Address - Street 2:APT 18
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2063
Mailing Address - Country:US
Mailing Address - Phone:201-660-5590
Mailing Address - Fax:
Practice Address - Street 1:14431 41ST AVE
Practice Address - Street 2:APT L2
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1452
Practice Address - Country:US
Practice Address - Phone:201-660-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00329300213ES0103X
NYN006752213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery