Provider Demographics
NPI:1508840018
Name:CHONG, BRIAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:CHONG
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 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:11750 W 2ND PL STE 255
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1726
Practice Address - Country:US
Practice Address - Phone:720-321-8040
Practice Address - Fax:720-321-8041
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332772085R0202X, 2085R0204X
CA506852085R0202X
CODR.00717802085R0204X, 2085R0202X
WAMD000396552085R0202X
MN630442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ893629Medicaid
AZ86080015085259A981OtherTRIWEST
AZ893629Medicaid
F68462Medicare UPIN