Provider Demographics
NPI:1972517910
Name:CHUNG, KIYON (MD)
Entity type:Individual
Prefix:
First Name:KIYON
Middle Name:
Last Name:CHUNG
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 1:4060 FOURTH AVE STE 650
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2121
Mailing Address - Country:US
Mailing Address - Phone:619-819-7222
Mailing Address - Fax:
Practice Address - Street 1:4060 FOURTH AVE STE 650
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2121
Practice Address - Country:US
Practice Address - Phone:619-819-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041132207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
C54514OtherCA LICEN SE
WAMD00041132OtherLICENSE
EZ780AMedicare PIN