Healthcare Provider Details

I. General information

NPI: 1194950683
Provider Name (Legal Business Name): JISUN CHA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 BROADWAY STE 1606
NEW YORK NY
10006-2562
US

IV. Provider business mailing address

10 LIBERTY ST APT 21C
NEW YORK NY
10005-1549
US

V. Phone/Fax

Practice location:
  • Phone: 267-737-8655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD465852
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD12915
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA09071200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number266475
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number25MA09071200
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMA09071200
License Number StateRI
# 7
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD465852
License Number StatePA
# 8
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number266475
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: