Provider Demographics
NPI:1912956855
Name:IM, TAE-WOONG (MD)
Entity Type:Individual
Prefix:DR
First Name:TAE-WOONG
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:28780 SINGLE OAK DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5528
Mailing Address - Country:US
Mailing Address - Phone:951-676-4193
Mailing Address - Fax:951-719-1469
Practice Address - Street 1:28780 SINGLE OAK DR
Practice Address - Street 2:SUITE 160
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5528
Practice Address - Country:US
Practice Address - Phone:951-676-4193
Practice Address - Fax:951-719-1469
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG72383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G723831Medicare PIN
F14992Medicare UPIN
ZZZ20970ZMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER