Provider Demographics
NPI:1902835549
Name:YOO, KI SOOK (MD)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:SOOK
Last Name:YOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 VAN BUREN DR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1337
Mailing Address - Country:US
Mailing Address - Phone:201-909-9898
Mailing Address - Fax:201-845-0840
Practice Address - Street 1:21 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1615
Practice Address - Country:US
Practice Address - Phone:201-909-9898
Practice Address - Fax:201-845-0840
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA598132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0047104Medicaid
NJ0047104Medicaid
NJG63510Medicare UPIN