Provider Demographics
NPI:1619939832
Name:CHUNG, KATHLEEN H (OD)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:H
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:P.O. BOX 647
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:AR
Mailing Address - Zip Code:72855
Mailing Address - Country:US
Mailing Address - Phone:479-963-2661
Mailing Address - Fax:479-963-6821
Practice Address - Street 1:25 E. WALNUT
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855
Practice Address - Country:US
Practice Address - Phone:479-963-2661
Practice Address - Fax:479-963-6821
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N406OtherBLUE CROSS AND BLUE SHIEL
AR159554722Medicaid
AR159544722Medicaid
ARV0772Medicare UPIN
AR5578210001Medicare NSC
5N406F412Medicare PIN
AR5N406OtherBLUE CROSS AND BLUE SHIEL