Basic Information
Provider Information | |||||||||
NPI: | 1922025618 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YO | ||||||||
FirstName: | SEUNG | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2101 E JEFFERSON ST | ||||||||
Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208524908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018162424 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11445 SUNSET HILLS RD | ||||||||
Address2: |   | ||||||||
City: | RESTON | ||||||||
State: | VA | ||||||||
PostalCode: | 201905276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037091500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 02/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD039182 | DC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101225839 | VA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0060078 | MD | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 60234801 | 01 | MD | BLUE SHIELD | OTHER | 405175100 | 05 | MD |   | MEDICAID | 80430037 | 01 | DC | BLUE SHIELD | OTHER |