Provider Demographics
NPI:1326031923
Name:CHUNG, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CHUNG
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 1:420 N MCKINLEY ST
Mailing Address - Street 2:111-616
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-6504
Mailing Address - Country:US
Mailing Address - Phone:951-321-0100
Mailing Address - Fax:951-321-0131
Practice Address - Street 1:4500 BROCKTON AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4090
Practice Address - Country:US
Practice Address - Phone:951-321-0100
Practice Address - Fax:951-321-0131
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G701470Medicaid
CA00G701471Medicare ID - Type Unspecified
F38988Medicare UPIN