Provider Demographics
NPI:1568644144
Name:NW FOOT CLINIC PC
Entity Type:Organization
Organization Name:NW FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-591-7449
Mailing Address - Street 1:4055 SW 185TH AVE
Mailing Address - Street 2:#100
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1567
Mailing Address - Country:US
Mailing Address - Phone:503-591-7449
Mailing Address - Fax:503-591-5826
Practice Address - Street 1:3895 SW 185TH AVE
Practice Address - Street 2:#140
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97078-1573
Practice Address - Country:US
Practice Address - Phone:503-591-7449
Practice Address - Fax:503-591-5826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00157213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67509Medicare UPIN
ORR131420Medicare PIN