Provider Demographics
NPI:1912561119
Name:YOON, ELISE JONGEUN (DO)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:JONGEUN
Last Name:YOON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DRIVE
Mailing Address - Street 2:SUITE #601
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DRIVE
Practice Address - Street 2:SUITE #601
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-569-7745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program