Healthcare Provider Details

I. General information

NPI: 1467024661
Provider Name (Legal Business Name): CRYSTAL CHEONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 MARKET ST STE 205
PHILADELPHIA PA
19104-2616
US

IV. Provider business mailing address

3624 MARKET ST STE 205
PHILADELPHIA PA
19104-2616
US

V. Phone/Fax

Practice location:
  • Phone: 484-743-4298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberMT224339
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: