Provider Demographics
NPI:1538391750
Name:JEONG, PETER TAEJOO (DC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:TAEJOO
Last Name:JEONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:TAEJOO
Other - Middle Name:
Other - Last Name:JEONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:10721 MAIN ST STE G7
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6913
Mailing Address - Country:US
Mailing Address - Phone:703-814-6650
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST STE G7
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6913
Practice Address - Country:US
Practice Address - Phone:703-814-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VV7085B658OtherMEDICARE PTAN