Provider Demographics
NPI:1629071840
Name:CHUNG, JAE W (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:W
Last Name:CHUNG
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 1:1 GUTHRIE DR
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3696
Mailing Address - Country:US
Mailing Address - Phone:607-973-7200
Mailing Address - Fax:607-937-7866
Practice Address - Street 1:1 GUTHRIE DR
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3696
Practice Address - Country:US
Practice Address - Phone:607-973-7200
Practice Address - Fax:607-937-7866
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07546600174400000X
NY2348/23207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0040886Medicaid
NJ081076Medicare ID - Type Unspecified
NJI04046Medicare UPIN