Provider Demographics
NPI:1053372003
Name:JUNG, LANCE (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:JUNG
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 1:55 WATER ST
Mailing Address - Street 2:12TH FL. CREDENTIALING
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3612
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198410208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01825121Medicaid
NYA400160687Medicare PIN
G38924Medicare UPIN