Provider Demographics
NPI:1124037882
Name:WANG, CHUN JU (DO)
Entity Type:Individual
Prefix:DR
First Name:CHUN JU
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:DEPT OF REHAB MEDICINE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-5906
Practice Address - Fax:410-601-6071
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11167208100000X
MDH0068125208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108057Medicaid
MDP00846986OtherR/R MEDICARE PTAN
MDCA8374OtherR/R MEDICARE GROUP PTAN
MDS588Medicare PIN
MDP00846986OtherR/R MEDICARE PTAN
ILI 113147Medicare UPIN