Provider Demographics
NPI:1417279308
Name:CHARLES R. CHUNG, M.D., P.A.
Entity Type:Organization
Organization Name:CHARLES R. CHUNG, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:817-267-1521
Mailing Address - Street 1:1850 CENTRAL DR #B
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5890
Mailing Address - Country:US
Mailing Address - Phone:817-267-1521
Mailing Address - Fax:817-267-1523
Practice Address - Street 1:1850 CENTRAL DR. #B
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5890
Practice Address - Country:US
Practice Address - Phone:817-267-1521
Practice Address - Fax:817-267-1523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3149207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111954702Medicaid
TXC14490Medicare UPIN
TX00P347Medicare PIN