Provider Demographics
NPI:1740290378
Name:CHUNG, MARK MICHAEL (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:MICHAEL
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:P.O. BOX 5279
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90721
Mailing Address - Country:US
Mailing Address - Phone:562-598-1002
Mailing Address - Fax:562-799-0115
Practice Address - Street 1:11821 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6825
Practice Address - Country:US
Practice Address - Phone:562-991-5679
Practice Address - Fax:562-991-5681
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52290207QS1201X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
A52227Medicare UPIN
CAG52290AMedicare ID - Type Unspecified