Provider Demographics
NPI:1295811966
Name:YOO, JAE YONG (MD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:YONG
Last Name:YOO
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 1:966 S WESTERN AVE
Mailing Address - Street 2:STE 208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1016
Mailing Address - Country:US
Mailing Address - Phone:323-731-2001
Mailing Address - Fax:323-731-1482
Practice Address - Street 1:966 S WESTERN AVE
Practice Address - Street 2:STE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-1016
Practice Address - Country:US
Practice Address - Phone:323-731-2001
Practice Address - Fax:323-731-1482
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A45421Medicaid
CAA45421Medicare ID - Type Unspecified
CA00A45421Medicaid