Provider Demographics
NPI:1336298835
Name:BANG, EUNSOOK (MD)
Entity Type:Individual
Prefix:
First Name:EUNSOOK
Middle Name:
Last Name:BANG
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 1:147-03 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-762-7793
Mailing Address - Fax:
Practice Address - Street 1:14703 41ST AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1248
Practice Address - Country:US
Practice Address - Phone:718-762-7793
Practice Address - Fax:718-461-0324
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152456173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD04025Medicare UPIN