Basic Information
| Provider Information | |||||||||
| NPI: | 1497731152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | JUNG | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIM | ||||||||
| OtherFirstName: | JUNG | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1723 WASHINGTON ST | ||||||||
| Address2: | APT 208 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021181820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177843570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1340 BOYLSTON STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172670900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4310 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 468671 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0705667 | 05 | MA | MEDICAID | AA45472 | 01 | MA | HARVARD PILGRIM HEALTH CA | OTHER | W16364 | 01 | MA | BCBS | OTHER |