Healthcare Provider Details

I. General information

NPI: 1720296767
Provider Name (Legal Business Name): JAE BOCK CHUNG MDOM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 REGENT STREET SUITE #301
MADISON WI
53715
US

IV. Provider business mailing address

780 REGENT STREET SUITE #301
MADISON WI
53715
US

V. Phone/Fax

Practice location:
  • Phone: 608-256-0808
  • Fax: 608-256-0808
Mailing address:
  • Phone: 608-256-0808
  • Fax: 608-256-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000825
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: