Provider Demographics
NPI:1962472662
Name:WANG, CHUNG Y (MD)
Entity Type:Individual
Prefix:
First Name:CHUNG
Middle Name:Y
Last Name:WANG
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 1:441 S LIVERNOIS
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2591
Mailing Address - Country:US
Mailing Address - Phone:248-656-9696
Mailing Address - Fax:248-656-5731
Practice Address - Street 1:1100 WEST UNIVERSITY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2591
Practice Address - Country:US
Practice Address - Phone:248-652-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033144207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101267702Medicaid
B44484Medicare UPIN
F36094003Medicare ID - Type Unspecified