Provider Demographics
NPI:1396063186
Name:JONG, SOONTRI S (MD)
Entity type:Individual
Prefix:DR
First Name:SOONTRI
Middle Name:S
Last Name:JONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 POND RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-7117
Mailing Address - Country:US
Mailing Address - Phone:217-954-0595
Mailing Address - Fax:
Practice Address - Street 1:407 POND RIDGE LN
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7117
Practice Address - Country:US
Practice Address - Phone:217-954-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-05880261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care