Provider Demographics
NPI:1295408375
Name:JOO, JIMIN (OD)
Entity type:Individual
Prefix:
First Name:JIMIN
Middle Name:
Last Name:JOO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 ARIANNA CRESCENT
Mailing Address - Street 2:
Mailing Address - City:VAUGHAN
Mailing Address - State:ON
Mailing Address - Zip Code:L6A 4Z9
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3405 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1635
Practice Address - Country:US
Practice Address - Phone:315-446-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist