Healthcare Provider Details

I. General information

NPI: 1972079762
Provider Name (Legal Business Name): PRACTICE OF DR. EDWIN CHUNG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 3RD AVE E
BRADENTON FL
34208-1013
US

IV. Provider business mailing address

6247 ANISE DR
SARASOTA FL
34238-5177
US

V. Phone/Fax

Practice location:
  • Phone: 941-216-3103
  • Fax: 941-921-1594
Mailing address:
  • Phone: 941-400-1700
  • Fax: 941-921-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWIN K CHUNG
Title or Position: OWNER
Credential: MD
Phone: 941-400-1700