Provider Demographics
NPI:1497731152
Name:CHAN, JUNG E (OD)
Entity Type:Individual
Prefix:DR
First Name:JUNG
Middle Name:E
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JUNG
Other - Middle Name:E
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1723 WASHINGTON ST
Mailing Address - Street 2:APT 208
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1820
Mailing Address - Country:US
Mailing Address - Phone:617-784-3570
Mailing Address - Fax:
Practice Address - Street 1:1340 BOYLSTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-267-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA468671OtherTUFTS HEALTH PLAN
MA0705667Medicaid
MAAA45472OtherHARVARD PILGRIM HEALTH CA
MAW16364OtherBCBS
MA0705667Medicaid
MA468671OtherTUFTS HEALTH PLAN