Provider Demographics
NPI:1285892158
Name:CHUNG, BO (MD)
Entity type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-3052
Mailing Address - Country:US
Mailing Address - Phone:213-999-0326
Mailing Address - Fax:
Practice Address - Street 1:801 E WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3052
Practice Address - Country:US
Practice Address - Phone:213-999-0326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVFH346ZMedicare UPIN