Healthcare Provider Details

I. General information

NPI: 1639661788
Provider Name (Legal Business Name): CHARLES CHANGIK CHUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR STE 500
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

788 N JEFFERSON ST STE 300
MILWAUKEE WI
53202-3710
US

V. Phone/Fax

Practice location:
  • Phone: 414-289-9669
  • Fax:
Mailing address:
  • Phone: 414-226-4025
  • Fax: 414-326-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number77142-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: