Provider Demographics
NPI:1518187657
Name:CHUNG, ILSEON
Entity Type:Individual
Prefix:
First Name:ILSEON
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4943 LA PALMA AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-2020
Mailing Address - Country:US
Mailing Address - Phone:562-924-5230
Mailing Address - Fax:562-924-5240
Practice Address - Street 1:4943 LA PALMA AVE STE D
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-2020
Practice Address - Country:US
Practice Address - Phone:562-924-5230
Practice Address - Fax:562-924-5240
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3260171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0032600Medicaid