Provider Demographics
NPI:1932206836
Name:CHONG, SOO H (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:H
Last Name:CHONG
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 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:510
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-481-0651
Mailing Address - Fax:
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:510
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-481-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA035654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35654Medicare PIN