Provider Demographics
NPI:1881906626
Name:YOO, KI-HYUK (DPM)
Entity type:Individual
Prefix:
First Name:KI-HYUK
Middle Name:
Last Name:YOO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 DORCHESTER AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5699
Mailing Address - Country:US
Mailing Address - Phone:617-696-5355
Mailing Address - Fax:617-696-5357
Practice Address - Street 1:2110 DORCHESTER AVE STE 203
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-696-5355
Practice Address - Fax:617-696-5357
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2398213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099331AMedicaid