Provider Demographics
NPI:1497784789
Name:JUNG, ICHABOD S (MD)
Entity Type:Individual
Prefix:
First Name:ICHABOD
Middle Name:S
Last Name:JUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 FOOTE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6947
Mailing Address - Country:US
Mailing Address - Phone:716-338-9200
Mailing Address - Fax:716-338-9250
Practice Address - Street 1:117 FOOTE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6947
Practice Address - Country:US
Practice Address - Phone:716-338-9200
Practice Address - Fax:716-338-9250
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY220355208800000X
PAMD417045208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2163913Medicaid
NYCC6336Medicare ID - Type Unspecified
NY2163913Medicaid