Provider Demographics
NPI:1861457459
Name:XIE, CHONGLUN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHONGLUN
Middle Name:
Last Name:XIE
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 1:5757 BOOTH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5980
Mailing Address - Country:US
Mailing Address - Phone:904-636-9510
Mailing Address - Fax:904-636-9512
Practice Address - Street 1:5757 BOOTH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5980
Practice Address - Country:US
Practice Address - Phone:904-636-9510
Practice Address - Fax:904-636-9512
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7245685OtherAETNA
FL16175OtherBCBS
2574641OtherUNITED HEALTH CARE
FL27393819Medicaid
I33853Medicare UPIN