Provider Demographics
NPI:1891925889
Name:JUNG, TAE WON (DO)
Entity Type:Individual
Prefix:DR
First Name:TAE
Middle Name:WON
Last Name:JUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5134
Mailing Address - Country:US
Mailing Address - Phone:916-784-4050
Mailing Address - Fax:
Practice Address - Street 1:1001 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5134
Practice Address - Country:US
Practice Address - Phone:916-784-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine