Provider Demographics
NPI:1417955758
Name:CHA, CHONG S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHONG
Middle Name:S
Last Name:CHA
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 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1031
Mailing Address - Country:US
Mailing Address - Phone:419-294-5358
Mailing Address - Fax:419-294-3221
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1031
Practice Address - Country:US
Practice Address - Phone:419-294-5358
Practice Address - Fax:419-294-3221
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-040362208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337773Medicaid
B95475Medicare UPIN
OH0337773Medicaid