Provider Demographics
NPI:1972673416
Name:CHUNG, MARK WR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WR
Last Name:CHUNG
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 1:40 AULIKE ST
Mailing Address - Street 2:SUITE 412
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734
Mailing Address - Country:US
Mailing Address - Phone:808-262-2424
Mailing Address - Fax:808-263-4882
Practice Address - Street 1:40 AULIKE ST
Practice Address - Street 2:SUITE 412
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-262-2424
Practice Address - Fax:808-263-4882
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI4560OtherHMSA
HI01592702Medicaid
HI17095OtherHMSA
E01190Medicare UPIN
0000BDLDDMedicare ID - Type Unspecified