Healthcare Provider Details

I. General information

NPI: 1992960850
Provider Name (Legal Business Name): AERIE CHUNG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WON K CHUNG MD

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/01/2023
Certification Date: 07/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 N MAIN ST STE 1C
MISHAWAKA IN
46545-3100
US

IV. Provider business mailing address

3838 N MAIN ST STE 1C
MISHAWAKA IN
46545-3100
US

V. Phone/Fax

Practice location:
  • Phone: 574-404-3980
  • Fax: 574-931-8601
Mailing address:
  • Phone: 574-404-3980
  • Fax: 574-931-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301091941
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number18339
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01072481A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: