Healthcare Provider Details

I. General information

NPI: 1528133410
Provider Name (Legal Business Name): RYAN TIEN-SI CHUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-1079 MOANALUA ROAD SUITE 555
AIEA HI
96701-4794
US

IV. Provider business mailing address

98-1079 MOANALUA ROAD SUITE 500
AIEA HI
96701-4794
US

V. Phone/Fax

Practice location:
  • Phone: 808-488-1943
  • Fax: 808-487-5291
Mailing address:
  • Phone: 808-488-1943
  • Fax: 808-487-5291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12721
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: