Provider Demographics
NPI:1295893709
Name:CHUNG, WAN SOO (MD)
Entity type:Individual
Prefix:
First Name:WAN
Middle Name:SOO
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 1:307 S MCCASKEY RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892
Mailing Address - Country:US
Mailing Address - Phone:252-792-1071
Mailing Address - Fax:252-792-1071
Practice Address - Street 1:307 S MCCASKEY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892
Practice Address - Country:US
Practice Address - Phone:252-792-1071
Practice Address - Fax:252-792-1071
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
22478OtherBLUE CROSS
NC8922478Medicaid
NC8922478Medicaid
D20657Medicare UPIN