Provider Demographics
NPI:1225032808
Name:KHAN, CHUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUNG
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W SOUTH 4TH ST
Mailing Address - Street 2:STE C
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 W SOUTH 4TH ST
Practice Address - Street 2:STE C
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1195
Practice Address - Country:US
Practice Address - Phone:618-282-8700
Practice Address - Fax:618-282-8703
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045245208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C38888Medicare UPIN