Provider Demographics
NPI:1740330356
Name:HAN, IN HO (MD)
Entity type:Individual
Prefix:
First Name:IN
Middle Name:HO
Last Name:HAN
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 1:1235 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4511
Mailing Address - Country:US
Mailing Address - Phone:631-436-7770
Mailing Address - Fax:631-436-9003
Practice Address - Street 1:1235 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4511
Practice Address - Country:US
Practice Address - Phone:631-436-7770
Practice Address - Fax:631-436-9003
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA173363-2207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01051692Medicaid
NYB02638Medicare UPIN
NY13E481Medicare ID - Type Unspecified