Provider Demographics
NPI:1306869417
Name:YI, WON SAM (MD)
Entity type:Individual
Prefix:
First Name:WON SAM
Middle Name:
Last Name:YI
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 1:168 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-5001
Mailing Address - Country:US
Mailing Address - Phone:563-556-3944
Mailing Address - Fax:563-594-5256
Practice Address - Street 1:350 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6388
Practice Address - Country:US
Practice Address - Phone:563-556-3944
Practice Address - Fax:563-594-5256
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1377172085R0001X, 208D00000X
NY2406282085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528637003OtherBLUE CROSS BLUE SHIELD WNY
NY3713862OtherINDEPENDENT HEALTH
NY00027662801OtherUNIVERA
NY02777448Medicaid
NYJ400000065Medicare PIN
NY000528637003OtherBLUE CROSS BLUE SHIELD WNY