Healthcare Provider Details

I. General information

NPI: 1992901219
Provider Name (Legal Business Name): TIMOTHY DANIEL CHONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2007
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16466 BERNARDO CENTER DR SUITE 150
SAN DIEGO CA
92128-2508
US

IV. Provider business mailing address

PO BOX 501724
SAN DIEGO CA
92150-1724
US

V. Phone/Fax

Practice location:
  • Phone: 858-453-7700
  • Fax: 858-798-1225
Mailing address:
  • Phone: 858-453-7700
  • Fax: 858-798-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMDR-5065
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA103353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: