Provider Demographics
NPI:1437110483
Name:HYUN, JONG D
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:D
Last Name:HYUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BONA VENTURE AVE
Mailing Address - Street 2:
Mailing Address - City:WALLKIN
Mailing Address - State:NY
Mailing Address - Zip Code:12589-4423
Mailing Address - Country:US
Mailing Address - Phone:845-895-3920
Mailing Address - Fax:845-778-4736
Practice Address - Street 1:96 BONA VENTURE AVE
Practice Address - Street 2:
Practice Address - City:WALLKIN
Practice Address - State:NY
Practice Address - Zip Code:12589-4423
Practice Address - Country:US
Practice Address - Phone:845-895-3920
Practice Address - Fax:845-778-4736
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00537715Medicaid
711917Medicare ID - Type Unspecified
NY00537715Medicaid