Provider Demographics
NPI:1083752133
Name:CHUNG, MIN JAE (LIA)
Entity type:Individual
Prefix:MR
First Name:MIN
Middle Name:JAE
Last Name:CHUNG
Suffix:
Gender:M
Credentials:LIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 VALLEY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3551
Mailing Address - Country:US
Mailing Address - Phone:301-738-7784
Mailing Address - Fax:
Practice Address - Street 1:600 VALLEY RD STE 101
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3551
Practice Address - Country:US
Practice Address - Phone:301-738-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01369171100000X
VA0121000393171100000X
NJ25MZ00074500171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist