Provider Demographics
NPI:1841458536
Name:CHUNG, CAROL (DO)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST FL 3
Mailing Address - Street 2:PHR GROUP PROVIDER ENROLLMENT UNIT
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:10945 LE CONTE AVE
Practice Address - Street 2:2339
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3000
Practice Address - Country:US
Practice Address - Phone:310-825-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A 1032B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program