Provider Demographics
NPI:1437389111
Name:CHUNG, BORAM (OD)
Entity Type:Individual
Prefix:DR
First Name:BORAM
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8136 SE FOSTER RD STE 260
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4288
Mailing Address - Country:US
Mailing Address - Phone:503-546-4460
Mailing Address - Fax:
Practice Address - Street 1:8136 SE FOSTER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4288
Practice Address - Country:US
Practice Address - Phone:503-546-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1745152W00000X
OR3312ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ163146Medicare PIN
AZZ162074Medicare PIN
AZZ162077Medicare PIN
AZZ163150Medicare PIN
AZZ163151Medicare PIN
AZZ163147Medicare PIN
AZZ162079Medicare PIN
AZZ163148Medicare PIN
AZZ163149Medicare PIN
AZ139211Medicare UPIN
AZZ162076Medicare PIN
AZZ162075Medicare PIN
AZZ162078Medicare PIN