Provider Demographics
NPI:1972780930
Name:OH, JEONG EUN (MD)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:EUN
Last Name:OH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-6748
Practice Address - Street 1:4 GROVE BEACH RD N
Practice Address - Street 2:BLDG1, UNIT A
Practice Address - City:WESTBROOK
Practice Address - State:CT
Practice Address - Zip Code:06498-1656
Practice Address - Country:US
Practice Address - Phone:860-664-3553
Practice Address - Fax:860-358-8656
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT046567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001633Medicaid
CT008001633Medicaid