Provider Demographics
NPI:1003194507
Name:CHUNG, KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14770 ORCHARD PKWY
Mailing Address - Street 2:UNIT 108
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80023-9127
Mailing Address - Country:US
Mailing Address - Phone:626-607-7500
Mailing Address - Fax:303-451-0626
Practice Address - Street 1:14451 ORCHARD PKWY
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023-9174
Practice Address - Country:US
Practice Address - Phone:303-451-0598
Practice Address - Fax:303-451-0626
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2907152W00000X
CA14542TLG152W00000X
AZ1976152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO042856Medicaid