Provider Demographics
NPI:1194950683
Name:CHA, JISUN (MD)
Entity type:Individual
Prefix:DR
First Name:JISUN
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LIBERTY ST APT 21C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-1549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 BROADWAY STE 1606
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2562
Practice Address - Country:US
Practice Address - Phone:267-737-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD465852207N00000X, 207ND0900X
RIMD12915207N00000X
NJ25MA09071200207N00000X, 207ND0900X
NY266475207N00000X, 207ND0900X
RIMA09071200207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0315176Medicaid
NJ0315176Medicaid