Provider Demographics
NPI:1770506412
Name:CHUNG, CHUNG-TAIK (MD)
Entity Type:Individual
Prefix:
First Name:CHUNG-TAIK
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PRESIDENTIAL PLZ
Mailing Address - Street 2:MADISON TOWERS SUITE 208
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2292
Mailing Address - Country:US
Mailing Address - Phone:315-464-2020
Mailing Address - Fax:315-464-2025
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5276
Practice Address - Fax:315-464-5939
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1190702085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY119070OtherNYS LICENSE
NY00470195Medicaid
B82238Medicare UPIN
NY00470195Medicaid