Basic Information
Provider Information | |||||||||
NPI: | 1770590507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAN | ||||||||
FirstName: | MYUNG | ||||||||
MiddleName: | KYU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HAN | ||||||||
OtherFirstName: | JAMES | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 11511 SHADOW CREEK PKWY | ||||||||
Address2: |   | ||||||||
City: | PEARLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 775847298 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134420000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15655 CYPRESS WOOD MEDICAL DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770141471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134421700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 04/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1787 | TX | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 207476703 | 05 | TX |   | MEDICAID | 207476704 | 05 | TX |   | MEDICAID | 207476702 | 05 | TX |   | MEDICAID |