Healthcare Provider Details

I. General information

NPI: 1942434535
Provider Name (Legal Business Name): DANIEL FREDERICK JUNG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CEDAR ST
METTER GA
30439-3338
US

IV. Provider business mailing address

PO BOX 2443
STATESBORO GA
30459-2443
US

V. Phone/Fax

Practice location:
  • Phone: 573-489-6691
  • Fax: 270-441-4925
Mailing address:
  • Phone: 573-489-6691
  • Fax: 513-981-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number74967
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number74967
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number252887-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: