Provider Demographics
NPI:1720083694
Name:CHUNG, PETER KAI-WONG (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:KAI-WONG
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 HALFORD AVE
Mailing Address - Street 2:# 168
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-3205
Mailing Address - Country:US
Mailing Address - Phone:408-247-0099
Mailing Address - Fax:408-556-6773
Practice Address - Street 1:1470 HALFORD AVE
Practice Address - Street 2:# 168
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-3205
Practice Address - Country:US
Practice Address - Phone:408-247-0099
Practice Address - Fax:408-556-6773
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63760Medicaid
CAH29937020A6376Medicare ID - Type Unspecified
CAH29937Medicare UPIN