Provider Demographics
NPI:1770512105
Name:CHUNG, KIRK P (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:P
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 1:5350 LAMME RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45439-3215
Mailing Address - Country:US
Mailing Address - Phone:937-534-4632
Mailing Address - Fax:937-534-4609
Practice Address - Street 1:5350 LAMME RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4632
Practice Address - Fax:937-534-4609
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0871782084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2630577Medicaid
OH000000391335OtherANTHEM
OHI50391Medicare UPIN
OH2630577Medicaid