Provider Demographics
NPI:1245638592
Name:SEO, DONGWHA
Entity type:Individual
Prefix:
First Name:DONGWHA
Middle Name:
Last Name:SEO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DON
Other - Middle Name:
Other - Last Name:SEO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15846 76TH AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1067
Mailing Address - Country:US
Mailing Address - Phone:718-885-7533
Mailing Address - Fax:
Practice Address - Street 1:15846 76TH AVE APT 1C
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1067
Practice Address - Country:US
Practice Address - Phone:718-885-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist