Provider Demographics
NPI:1720032840
Name:CHUNG, ROBERTA GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:GAIL
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-2233
Mailing Address - Country:US
Mailing Address - Phone:877-423-1330
Mailing Address - Fax:407-877-2166
Practice Address - Street 1:17 E OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-2233
Practice Address - Country:US
Practice Address - Phone:877-423-1330
Practice Address - Fax:407-877-2166
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00069406OtherRAILROAD MEDICARE NUMBER
FLP00069406OtherRAILROAD MEDICARE NUMBER
H69965Medicare UPIN
51330YMedicare ID - Type Unspecified