Provider Demographics
NPI:1982661823
Name:CHUNG, CHARLES J (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
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:PO BOX 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1312732085B0100X, 2085B0100X
ARE-165112085R0202X
NC96008862085R0202X
NY2347012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050922000000OtherFIDELIS
NY2347011WOtherNYS WORKERS COMPENSATION
P00193057OtherRR MEDICARE
000528052007OtherBLUE SHIELD WNY
0142853OtherGHI
P020234701OtherBLUE SHIELD OF ROCHESTER
NY000528052001OtherBLUE SHIELD WNY
NY01756523Medicaid
1612812OtherINDEPENDENT HEALTH
196562FFOtherPREFERRED CARE
P00232918OtherRR MEDICARE
P010234701OtherBLUE CHOICE
4193544OtherGHI
00027018501OtherUNIVERA
00027018504OtherUNIVERA
P00232918OtherRR MEDICARE
050922000000OtherFIDELIS
NY2347011WOtherNYS WORKERS COMPENSATION
NYRA5960Medicare ID - Type Unspecified