Provider Demographics
NPI:1962415588
Name:JUNG, SUSAN C (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:JUNG
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 1:923 S SAN GABRIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2847
Mailing Address - Country:US
Mailing Address - Phone:626-286-8700
Mailing Address - Fax:626-286-8650
Practice Address - Street 1:923 S SAN GABRIEL BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-2847
Practice Address - Country:US
Practice Address - Phone:626-286-8700
Practice Address - Fax:626-286-8650
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A855420Medicaid
CAI72746Medicare UPIN
CAWA85542AMedicare PIN