Provider Demographics
NPI:1760417471
Name:CHUNG, SUSIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
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:PO BOX 1418
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10156-1418
Mailing Address - Country:US
Mailing Address - Phone:347-392-7474
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST. SUITE 320
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3100
Practice Address - Country:US
Practice Address - Phone:212-334-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211617207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01987842Medicaid
H08842Medicare UPIN
NY54C101Medicare ID - Type Unspecified