Provider Demographics
NPI:1710636899
Name:HAN, CHONG SUP (MD)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:SUP
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:HAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:101 SAINT ANDREWS LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2254
Mailing Address - Country:US
Mailing Address - Phone:516-674-7631
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2254
Practice Address - Country:US
Practice Address - Phone:516-674-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program