Provider Demographics
NPI:1235753245
Name:CHUNG, MICHELLE
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14020 SANFORD AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2559
Mailing Address - Country:US
Mailing Address - Phone:718-762-3838
Mailing Address - Fax:
Practice Address - Street 1:14020 SANFORD AVE APT 1C
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2559
Practice Address - Country:US
Practice Address - Phone:718-762-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist