Provider Demographics
NPI:1750636726
Name:JUNG, MYUNG H (OD)
Entity Type:Individual
Prefix:
First Name:MYUNG
Middle Name:H
Last Name:JUNG
Suffix:
Gender:F
Credentials:OD
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 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2517 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2409
Practice Address - Country:US
Practice Address - Phone:360-748-8632
Practice Address - Fax:360-748-3869
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60394858152W00000X
ORAT3523152W00000X
NY007851152W00000X
NJ27OA00642700152W00000X
OR3523AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1750636726Medicaid
WA2060397Medicaid