Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 29969 | TX |
Y | 213EG0000X | General Practice | 29969 | TX |
NPI | 1003222811 |
---|---|
Provider Name | Chungmi Jo |
First Address | Fort Worth, TX 76244-7650 |
Second Address | Waxahachie, TX 75165-4706 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2014 |
Last Update Date | 01/07/2014 |