Provider Demographics
NPI:1235310756
Name:CHU, GORDON KT (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:KT
Last Name:CHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOWK TUNG
Other - Middle Name:
Other - Last Name:CHU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST STE 400
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-351-4972
Practice Address - Fax:618-351-4973
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119245207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119245Medicaid
IL036119245Medicaid
T01778Medicare PIN