Provider Demographics
NPI:1982028130
Name:YETASOOK, AMY KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:KIM
Last Name:YETASOOK
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 1:2114 W DIVISION ST
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3035
Mailing Address - Country:US
Mailing Address - Phone:213-268-5421
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION DEPARTMENT
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-326-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063845208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery