Provider Demographics
NPI:1891702718
Name:CHUNG, CHIN W (MD)
Entity type:Individual
Prefix:
First Name:CHIN
Middle Name:W
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 1:24891 STONEGATE LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-8809
Mailing Address - Country:US
Mailing Address - Phone:917-415-7656
Mailing Address - Fax:
Practice Address - Street 1:24891 STONEGATE LN
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-8809
Practice Address - Country:US
Practice Address - Phone:917-415-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC129000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00775484Medicaid
NY83933Medicare ID - Type Unspecified
NY00775484Medicaid