Healthcare Provider Details

I. General information

NPI: 1902809684
Provider Name (Legal Business Name): PHILIP R CHUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 HERITAGE VILLAGE PLZ SUITE 101
GAINESVILLE VA
20155-3079
US

IV. Provider business mailing address

7300 HERITAGE VILLAGE PLZ SUITE 101
GAINESVILLE VA
20155-3079
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-4733
  • Fax: 703-753-2183
Mailing address:
  • Phone: 703-753-4733
  • Fax: 703-753-2183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberL7335
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101239485
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: