Provider Demographics
NPI:1033748660
Name:JI, SEUNG YONG (MD)
Entity type:Individual
Prefix:
First Name:SEUNG YONG
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEVEN
Other - Middle Name:
Other - Last Name:JI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2001 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0802
Mailing Address - Country:US
Mailing Address - Phone:215-350-4624
Mailing Address - Fax:
Practice Address - Street 1:900 N LIBERTY ST STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8707
Practice Address - Country:US
Practice Address - Phone:208-336-4368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG220922207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology