Provider Demographics
NPI:1417362302
Name:JEONG, KEVIN (DPM)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 STOCKHOLM ST
Mailing Address - Street 2:DEPARTMENT OF PODIATRY
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:425-512-6870
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:DEPARTMENT OF PODIATRY
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:425-512-6870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR93511213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist