Provider Demographics
NPI:1770527327
Name:CHUNG, MARILDA HERNANDEZ (MD)
Entity type:Individual
Prefix:
First Name:MARILDA
Middle Name:HERNANDEZ
Last Name:CHUNG
Suffix:
Gender:F
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:PO BOX 29364
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0364
Mailing Address - Country:US
Mailing Address - Phone:415-353-6338
Mailing Address - Fax:
Practice Address - Street 1:900 HYDE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4806
Practice Address - Country:US
Practice Address - Phone:415-353-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74478207ZP0101X, 207ZP0102X, 207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G744780Medicaid
CA00G744780Medicare PIN
CAG38106Medicare UPIN