Provider Demographics
NPI:1871366013
Name:IM, YONG CHOL (OD)
Entity type:Individual
Prefix:
First Name:YONG
Middle Name:CHOL
Last Name:IM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1215 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-7021
Mailing Address - Country:US
Mailing Address - Phone:214-924-7069
Mailing Address - Fax:
Practice Address - Street 1:6464 E NORTHWEST HWY STE 309
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-7808
Practice Address - Country:US
Practice Address - Phone:469-248-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11015T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist