Provider Demographics
NPI:1205917176
Name:JUNG, RANDY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JOHN
Last Name:JUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62222-0354
Mailing Address - Country:US
Mailing Address - Phone:618-235-1582
Mailing Address - Fax:618-235-2473
Practice Address - Street 1:301 W LINCOLN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1901
Practice Address - Country:US
Practice Address - Phone:618-235-1582
Practice Address - Fax:618-235-2473
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360859902084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085990Medicaid
ILK47563Medicare PIN
IL036085990Medicaid