Provider Demographics
NPI:1992783211
Name:SIEDLECKI, CHUNG (MD)
Entity type:Individual
Prefix:DR
First Name:CHUNG
Middle Name:
Last Name:SIEDLECKI
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 1:1515 TRUEMPER ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-292-3613
Mailing Address - Fax:210-292-3628
Practice Address - Street 1:1515 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5583
Practice Address - Country:US
Practice Address - Phone:210-292-3613
Practice Address - Fax:210-292-3628
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 051665171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider