Provider Demographics
NPI:1053958819
Name:CHO, MIKYONG (RD)
Entity type:Individual
Prefix:
First Name:MIKYONG
Middle Name:
Last Name:CHO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2711
Mailing Address - Country:US
Mailing Address - Phone:917-568-2773
Mailing Address - Fax:
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:201-833-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-28
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
876963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered