Provider Demographics
NPI:1053371393
Name:CHUNG, KWANG P (MD)
Entity type:Individual
Prefix:MR
First Name:KWANG
Middle Name:P
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 1:903 GREENBRIER ROAD
Mailing Address - Street 2:PO BOX 607
Mailing Address - City:EARLVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60518
Mailing Address - Country:US
Mailing Address - Phone:815-246-6344
Mailing Address - Fax:815-246-4711
Practice Address - Street 1:903 GREENBRIER ROAD
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:IL
Practice Address - Zip Code:60518-0607
Practice Address - Country:US
Practice Address - Phone:815-246-6344
Practice Address - Fax:815-246-4711
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0005000240OtherBC BS
211660Medicare ID - Type Unspecified
0005000240OtherBC BS