Provider Demographics
NPI:1093939357
Name:JUNG, STEPHANO
Entity Type:Individual
Prefix:MR
First Name:STEPHANO
Middle Name:
Last Name:JUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CHAECHUNG
Other - Middle Name:
Other - Last Name:JUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 FEDORA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2586
Mailing Address - Country:US
Mailing Address - Phone:213-380-5670
Mailing Address - Fax:
Practice Address - Street 1:1010 FEDORA ST STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2586
Practice Address - Country:US
Practice Address - Phone:213-380-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5255171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0052550Medicaid