Provider Demographics
NPI:1417436130
Name:CHONG, BENJAMIN HAN WOOK (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:HAN WOOK
Last Name:CHONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 MONTREAL ROAD EAST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-491-0920
Mailing Address - Fax:770-491-0906
Practice Address - Street 1:1460 MONTREAL ROAD EAST
Practice Address - Street 2:SUITE 300
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-491-0920
Practice Address - Fax:770-491-0906
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist