Healthcare Provider Details

I. General information

NPI: 1821208240
Provider Name (Legal Business Name): KYUNGHOON CHUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5150
  • Fax:
Mailing address:
  • Phone: 602-521-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number55134
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: