Provider Demographics
NPI:1609339480
Name:CHUA, CHARLES EDRICK ONG
Entity Type:Individual
Prefix:MR
First Name:CHARLES EDRICK
Middle Name:ONG
Last Name:CHUA
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 1:401 ROUTE 73 N STE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:693 MAIN STREET
Practice Address - Street 2:BUILDING D SUITE 1
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048
Practice Address - Country:US
Practice Address - Phone:609-261-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11514500208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program