Provider Demographics
NPI:1790496107
Name:CHANGSOO MEDICAL GROUP
Entity Type:Organization
Organization Name:CHANGSOO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:562-335-0008
Mailing Address - Street 1:5832 BEACH BLVD UNIT 214
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-5501
Mailing Address - Country:US
Mailing Address - Phone:714-523-7575
Mailing Address - Fax:
Practice Address - Street 1:5832 BEACH BLVD UNIT 214
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-5501
Practice Address - Country:US
Practice Address - Phone:714-523-7575
Practice Address - Fax:714-523-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty