Healthcare Provider Details

I. General information

NPI: 1992783211
Provider Name (Legal Business Name): CHUNG SIEDLECKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 TRUEMPER ST
LACKLAND A F B TX
78236-5583
US

IV. Provider business mailing address

1515 TRUEMPER ST
LACKLAND AFB TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-3613
  • Fax: 210-292-3628
Mailing address:
  • Phone: 210-292-3613
  • Fax: 210-292-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberMD 051665
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: