Healthcare Provider Details

I. General information

NPI: 1770512105
Provider Name (Legal Business Name): KIRK P CHUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 LAMME RD
DAYTON OH
45439-3215
US

IV. Provider business mailing address

5350 LAMME RD
DAYTON OH
45439-3215
US

V. Phone/Fax

Practice location:
  • Phone: 937-534-4632
  • Fax: 937-534-4609
Mailing address:
  • Phone: 937-534-4632
  • Fax: 937-534-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35-087178
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: