Provider Demographics
NPI:1538169552
Name:YOON, CHANG GOO (PT,DPT)
Entity type:Individual
Prefix:DR
First Name:CHANG
Middle Name:GOO
Last Name:YOON
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5322
Mailing Address - Country:US
Mailing Address - Phone:617-731-1004
Mailing Address - Fax:617-879-9012
Practice Address - Street 1:44 WASHINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7130
Practice Address - Country:US
Practice Address - Phone:617-731-1004
Practice Address - Fax:617-731-1001
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18660225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0936OtherBCBS
DC0936OtherBCBS