Provider Demographics
NPI:1720122179
Name:JOO, JAE WOUN (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:WOUN
Last Name:JOO
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 1:1203 PARRILLA DE AVILA
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1082
Mailing Address - Country:US
Mailing Address - Phone:813-969-0033
Mailing Address - Fax:813-969-0033
Practice Address - Street 1:1203 PARRILLA DE AVILA
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1082
Practice Address - Country:US
Practice Address - Phone:813-969-0033
Practice Address - Fax:813-969-0033
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030306146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE11927Medicare UPIN