Provider Demographics
NPI:1821073107
Name:CHUNG, KEUN SAM (MD)
Entity Type:Individual
Prefix:
First Name:KEUN
Middle Name:SAM
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:PO BOX 9805
Mailing Address - Street 2:300 GEORGE STREET 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH TOMPKINS BUILDING 3RD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8900
Practice Address - Country:US
Practice Address - Phone:203-785-2802
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018808207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001188085Medicaid
D02999Medicare UPIN
CT001188085Medicaid
CT050000071Medicare ID - Type Unspecified