Provider Demographics
NPI:1720296767
Name:CHUNG, JAE BOCK (MDOM PHD)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:BOCK
Last Name:CHUNG
Suffix:
Gender:M
Credentials:MDOM PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:780 REGENT STREET
Mailing Address - Street 2:SUITE #301
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715
Mailing Address - Country:US
Mailing Address - Phone:608-256-0808
Mailing Address - Fax:608-256-0808
Practice Address - Street 1:780 REGENT STREET
Practice Address - Street 2:SUITE #301
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715
Practice Address - Country:US
Practice Address - Phone:608-256-0808
Practice Address - Fax:608-256-0808
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI000825171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist