Basic Information
| Provider Information | |||||||||
| NPI: | 1134298177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | Y. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 GEORGIANA ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605650999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 907 GEORGIANA ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605650999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 12/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | A70974 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | MD00037817 | WA | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | A70974 | CA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0100250 | 05 | CA | MEDICAID | MD00037817 | 01 | WA | WA MEDICAL LICENSE | OTHER | A70974 | 01 | CA | CA MEDICAL LICENSE | OTHER |