Provider Demographics
NPI:1790726388
Name:CHUNG, JIN BAIK (MD)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:BAIK
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 1:220 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45345-1299
Mailing Address - Country:US
Mailing Address - Phone:937-687-1331
Mailing Address - Fax:937-687-3216
Practice Address - Street 1:220 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45345-1299
Practice Address - Country:US
Practice Address - Phone:937-687-1331
Practice Address - Fax:937-687-3216
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.042055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364056Medicaid
OH0448082Medicare PIN
OH0364056Medicaid