Provider Demographics
NPI:1427041730
Name:CHUN, WALLACE ERIC (MD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:ERIC
Last Name:CHUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:CHUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 100
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2600
Practice Address - Fax:208-262-2700
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8003207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1427041730Medicaid
IDHBTD8OtherBLUE CROSS
IDHBTD8OtherBLUE CROSS
ID1143647Medicare ID - Type UnspecifiedMEDICARE