Provider Demographics
NPI:1992960850
Name:CHUNG, AERIE (MD)
Entity type:Individual
Prefix:DR
First Name:AERIE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WON
Other - Middle Name:K
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3838 N MAIN ST STE 1C
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3100
Mailing Address - Country:US
Mailing Address - Phone:574-404-3980
Mailing Address - Fax:574-931-8601
Practice Address - Street 1:3838 N MAIN ST STE 1C
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3100
Practice Address - Country:US
Practice Address - Phone:574-404-3980
Practice Address - Fax:574-931-8601
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091941207R00000X
WI18339207RI0200X
IN01072481A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01703901OtherRR MEDICARE
IN1877200008OtherMEDICARE
IN201163410Medicaid
IN1877200008OtherMEDICARE