Healthcare Provider Details

I. General information

NPI: 1962637827
Provider Name (Legal Business Name): JERELL DIEGO CHUA MPH, D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 WILKINSON BLVD STE 130
CHARLOTTE NC
28208-5698
US

IV. Provider business mailing address

4700 MILLENIA BLVD STE 650
ORLANDO FL
32839-6013
US

V. Phone/Fax

Practice location:
  • Phone: 980-575-1254
  • Fax:
Mailing address:
  • Phone: 407-533-6837
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023-03221
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1620
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: