Basic Information
| Provider Information | |||||||||
| NPI: | 1497784789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUNG | ||||||||
| FirstName: | ICHABOD | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 FOOTE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389200 | ||||||||
| FaxNumber: | 7163389250 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 FOOTE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389200 | ||||||||
| FaxNumber: | 7163389250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 02/03/2011 | ||||||||
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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 | 208800000X | 220355 | NY | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD417045 | PA | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2163913 | 05 | NY | MEDICAID |