Provider Demographics
NPI:1851315410
Name:SO, CHUN HO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUN
Middle Name:HO
Last Name:SO
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 1:1050 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:
Practice Address - Street 1:1000 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-364-9000
Practice Address - Fax:573-458-8490
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112090207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1851315410Medicaid
MOH51821Medicare UPIN
MO908783230Medicare PIN
MO110246316Medicare ID - Type UnspecifiedRR MDCR PROV. #
MO1851315410Medicaid