Provider Demographics
NPI:1619953197
Name:JUNG, BONG (MD)
Entity Type:Individual
Prefix:DR
First Name:BONG
Middle Name:
Last Name:JUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 TOWNE CENTRE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2818
Mailing Address - Country:US
Mailing Address - Phone:989-791-4718
Mailing Address - Fax:989-791-4882
Practice Address - Street 1:4705 TOWNE CENTRE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-791-4718
Practice Address - Fax:989-791-4882
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBJ0401382084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
104020OtherGREAT LAKES HEALTH PLAN
130026263OtherTRAVELERS MEDICARE
MI1748983Medicaid
0730194OtherBLUE CROSS
MI1307309121OtherHEALTH PLUS
1307309121OtherBLUE CARE NETWORK
1307309121OtherBLUE CARE NETWORK
MI1748983Medicaid