Basic Information
| Provider Information | |||||||||
| NPI: | 1194399014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAM | ||||||||
| FirstName: | MYUNGWOO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E149TH STREET | ||||||||
| Address2: | SUITE 8-20 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8210894791 | ||||||||
| FaxNumber: | 7185794836 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 E149TH STREET | ||||||||
| Address2: | SUITE 8-20 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185794719 | ||||||||
| FaxNumber: | 7185794836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2021 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/31/2022 | ||||||||
| NPIReactivationDate: | 11/03/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.