Provider Demographics
NPI:1194779694
Name:HONG, JUNG-SOO JOHN (MD)
Entity type:Individual
Prefix:
First Name:JUNG-SOO
Middle Name:JOHN
Last Name:HONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8769
Mailing Address - Fax:410-328-3577
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8769
Practice Address - Fax:410-328-3577
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD53765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD802103101Medicaid
MDS062-0345OtherBC/BS - REGIONAL
DC034622900Medicaid
MD675349-03OtherBC/BS GREENE ST
VA005883547Medicaid
MDP00842517Medicare PIN
DC034622900Medicaid
VA005883547Medicaid