Healthcare Provider Details

I. General information

NPI: 1760732036
Provider Name (Legal Business Name): JOHN WUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S. CALIFORNIA AVE
CHICAGO IL
60608
US

IV. Provider business mailing address

2801 S KING DR APT 1615
CHICAGO IL
60616-2989
US

V. Phone/Fax

Practice location:
  • Phone: 614-507-0311
  • Fax:
Mailing address:
  • Phone: 614-507-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.131204
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: