1720296767 NPI number — DR. JAE BOCK CHUNG MDOM PHD

Table of content: DR. JAE BOCK CHUNG MDOM PHD (NPI 1720296767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720296767 NPI number — DR. JAE BOCK CHUNG MDOM PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHUNG
Provider First Name:
JAE
Provider Middle Name:
BOCK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MDOM PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720296767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 REGENT STREET
Provider Second Line Business Mailing Address:
SUITE #301
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-256-0808
Provider Business Mailing Address Fax Number:
608-256-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 REGENT STREET
Provider Second Line Business Practice Location Address:
SUITE #301
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-256-0808
Provider Business Practice Location Address Fax Number:
608-256-0808
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  000825 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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