Provider Demographics
NPI:1376105825
Name:CHA, JONGWHAN
Entity Type:Individual
Prefix:
First Name:JONGWHAN
Middle Name:
Last Name:CHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 DOLSON AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-6560
Mailing Address - Country:US
Mailing Address - Phone:845-381-2688
Mailing Address - Fax:
Practice Address - Street 1:156 DOLSON AVE STE 11
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6560
Practice Address - Country:US
Practice Address - Phone:845-381-2688
Practice Address - Fax:845-345-8201
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000929171100000X
NY006683171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist