Provider Demographics
NPI:1417914557
Name:CHUNG, DAVID TAEWOONG (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:TAEWOONG
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 1:1300 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1048
Mailing Address - Country:US
Mailing Address - Phone:618-443-3084
Mailing Address - Fax:618-443-2956
Practice Address - Street 1:1300 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1048
Practice Address - Country:US
Practice Address - Phone:618-443-4138
Practice Address - Fax:618-443-2956
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH33052Medicare UPIN