Healthcare Provider Details

I. General information

NPI: 1578149670
Provider Name (Legal Business Name): DEREK SHANE CHUNG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 E SEMINOLE ST
SPRINGFIELD MO
65804-2227
US

IV. Provider business mailing address

1229 E SEMINOLE ST
SPRINGFIELD MO
65804-2227
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2064
  • Fax:
Mailing address:
  • Phone: 417-820-2064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number14209965-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2026016489
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: