Healthcare Provider Details

I. General information

NPI: 1063401610
Provider Name (Legal Business Name): JAY SOO JUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17TH & CHEW STREET
ALLENTOWN PA
18102
US

IV. Provider business mailing address

1245 S CEDAR CREST BLVD SUITE #301
ALLENTOWN PA
18103-6258
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-9029
  • Fax: 610-402-9029
Mailing address:
  • Phone: 610-402-9080
  • Fax: 610-402-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD031217L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: