Healthcare Provider Details

I. General information

NPI: 1134120496
Provider Name (Legal Business Name): YOON-TAEK CHUN M.D.,FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 PROSPECT ST
E STROUDSBURG PA
18301-2943
US

IV. Provider business mailing address

263 PROSPECT ST
E STROUDSBURG PA
18301-2943
US

V. Phone/Fax

Practice location:
  • Phone: 570-421-3575
  • Fax:
Mailing address:
  • Phone: 570-421-3575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD030828E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00947786
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: