Provider Demographics
NPI:1093178923
Name:JEFFREY Y H CHUNG LLC
Entity Type:Organization
Organization Name:JEFFREY Y H CHUNG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-755-0693
Mailing Address - Street 1:311 PARK PLACE BLVD FL 5
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14201 LAUREL PARK DR STE 104
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5203
Practice Address - Country:US
Practice Address - Phone:727-755-0693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67554332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD418338000Medicaid
MD158475Medicare UPIN