Provider Demographics
NPI:1790538619
Name:JIN, ANDY YONGTAE (DO)
Entity type:Individual
Prefix:DR
First Name:ANDY
Middle Name:YONGTAE
Last Name:JIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:YONG TAE
Other - Middle Name:
Other - Last Name:JIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:313-315 LAKE STREET
Mailing Address - Street 2:APT 304
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104
Mailing Address - Country:US
Mailing Address - Phone:201-403-6615
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program