Healthcare Provider Details

I. General information

NPI: 1952582041
Provider Name (Legal Business Name): JIN YOUNG CHUNG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2007
Last Update Date: 11/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E MOUNT HOPE AVE
LANSING MI
48910-3207
US

IV. Provider business mailing address

425 RYDER RD APT 315
LANSING MI
48917-1016
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-3401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101016606
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: