Provider Demographics
NPI:1982868329
Name:SHON, WONWOO (DO)
Entity Type:Individual
Prefix:
First Name:WONWOO
Middle Name:
Last Name:SHON
Suffix:
Gender:M
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:PO BOX 100275
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:BOX 100275
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0275
Practice Address - Country:US
Practice Address - Phone:352-273-7841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52067207ZP0102X, 207N00000X
390200000X
FLOS12056207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008876900Medicaid
MNENROLLEDMedicaid
FL008876900Medicaid
FLHG524ZMedicare PIN
MN220001364Medicare PIN