Provider Demographics
NPI:1154423135
Name:HA, JIN BONG (OD)
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:BONG
Last Name:HA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 54TH ST APT 6T
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4215
Mailing Address - Country:US
Mailing Address - Phone:917-518-7375
Mailing Address - Fax:
Practice Address - Street 1:3960 54TH ST APT 6T
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4215
Practice Address - Country:US
Practice Address - Phone:917-518-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist