Healthcare Provider Details

I. General information

NPI: 1740290378
Provider Name (Legal Business Name): MARK MICHAEL CHUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11821 SOUTH ST
CERRITOS CA
90703-6825
US

IV. Provider business mailing address

P.O. BOX 5279
LOS ALAMITOS CA
90721
US

V. Phone/Fax

Practice location:
  • Phone: 562-991-5679
  • Fax: 562-991-5681
Mailing address:
  • Phone: 562-598-1002
  • Fax: 562-799-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License NumberG52290
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG52290
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG52290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: