Provider Demographics
NPI:1639301641
Name:CHAN, CHUNG MING (MB,BS)
Entity Type:Individual
Prefix:
First Name:CHUNG MING
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:MB,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 NW 13TH ST
Mailing Address - Street 2:PMB 251
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-2835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 HULL RD
Practice Address - Street 2:BOX 112727
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4144
Practice Address - Country:US
Practice Address - Phone:352-273-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118688207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJA171ZOtherMEDICARE PTAN
FL021309100Medicaid