Provider Demographics
NPI:1578149670
Name:CHUNG, DEREK SHANE (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:SHANE
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-7183
Mailing Address - Country:US
Mailing Address - Phone:816-288-9115
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD # M260
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-977-1753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program