Provider Demographics
NPI:1790167492
Name:JUNG, GRACE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ANN
Last Name:JUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:ANN
Other - Last Name:PAGUNURAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22015 AVALON BLVD
Mailing Address - Street 2:A
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3355
Mailing Address - Country:US
Mailing Address - Phone:310-830-7584
Mailing Address - Fax:
Practice Address - Street 1:22015 AVALON BLVD
Practice Address - Street 2:A
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3355
Practice Address - Country:US
Practice Address - Phone:310-830-7584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist