Provider Demographics
NPI:1598968463
Name:CHUNG, CAMILLE (OD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 S. MC CLINTOCK DR.
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283
Mailing Address - Country:US
Mailing Address - Phone:480-967-4910
Mailing Address - Fax:
Practice Address - Street 1:7511 S. MC CLINTOCK DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283
Practice Address - Country:US
Practice Address - Phone:480-967-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU83396Medicare UPIN