Healthcare Provider Details

I. General information

NPI: 1346636636
Provider Name (Legal Business Name): JAE CHUNG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22395 EDGEWATER DR
PORT CHARLOTTE FL
33980-2012
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 941-766-7222
  • Fax: 941-766-0970
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME150694
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: