Provider Demographics
NPI:1720078546
Name:YOO, DONG HO (MD)
Entity Type:Individual
Prefix:
First Name:DONG
Middle Name:HO
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:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-3235
Mailing Address - Country:US
Mailing Address - Phone:810-240-9475
Mailing Address - Fax:810-695-5192
Practice Address - Street 1:1359 KINGS CARRIAGE RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8786
Practice Address - Country:US
Practice Address - Phone:810-240-9475
Practice Address - Fax:810-695-5192
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010404032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2602500582OtherBCBS OF MI
MI2117281Medicaid
MI2117281Medicaid
MIB45510Medicare UPIN