Provider Demographics
NPI:1144008467
Name:HWANG, JOON TAE (IDC)
Entity type:Individual
Prefix:
First Name:JOON
Middle Name:TAE
Last Name:HWANG
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 W DRYDEN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2351
Mailing Address - Country:US
Mailing Address - Phone:747-257-7504
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICAL CENTER SAN DIEGO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:747-257-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman