Provider Demographics
NPI:1942305685
Name:NA, ILL SUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:ILL SUNG
Middle Name:
Last Name:NA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4015
Mailing Address - Country:US
Mailing Address - Phone:718-292-4640
Mailing Address - Fax:718-292-4640
Practice Address - Street 1:477 WILLIS AVE
Practice Address - Street 2:NARCO FREEDOM
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4015
Practice Address - Country:US
Practice Address - Phone:718-292-4640
Practice Address - Fax:718-292-4640
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00787875Medicaid
NY00787875Medicaid