Provider Demographics
NPI:1639148166
Name:CHUNG, TED (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0936
Mailing Address - Country:US
Mailing Address - Phone:850-837-0442
Mailing Address - Fax:850-837-1051
Practice Address - Street 1:4012 COMMONS DR W
Practice Address - Street 2:SUITE 100
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8422
Practice Address - Country:US
Practice Address - Phone:850-837-0442
Practice Address - Fax:850-837-1051
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0072919208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF92203Medicare UPIN