Provider Demographics
NPI:1104825124
Name:CHUNG, SERINA T (MD)
Entity Type:Individual
Prefix:DR
First Name:SERINA
Middle Name:T
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-2321
Mailing Address - Country:US
Mailing Address - Phone:516-295-4481
Mailing Address - Fax:516-295-4809
Practice Address - Street 1:1157 BROADWAY
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-2321
Practice Address - Country:US
Practice Address - Phone:516-295-4481
Practice Address - Fax:516-295-4809
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210666207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02086666Medicaid
NY02086666Medicaid
NY03406QMedicare PIN
NY852121Medicare ID - Type Unspecified