Provider Demographics
NPI:1760418743
Name:CHUNG, KELLY DENISE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
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 22009
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-558-7372
Mailing Address - Fax:503-344-5140
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:SUITE 961
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-292-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19039207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065271Medicaid
OR065271Medicaid
180040673OtherRAILROAD MEDICARE
ORR147566Medicare PIN