Provider Demographics
NPI:1922528504
Name:CHUNG, ERIN A (DO)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:A
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:1050 REID PARKWAY, SUITE 300
Practice Address - Street 2:REID HOSPITAL FAMILY MEDICINE RESIDENCY
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-966-9549
Practice Address - Fax:765-962-6268
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11019403A390200000X
OH34.014241207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408209Medicaid