Basic Information
| Provider Information | |||||||||
| NPI: | 1588608111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | CHUNG | ||||||||
| MiddleName: | QUAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 890 W STETSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925437311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 890 W STETSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925437311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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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 | 2085R0202X | A32875 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300049524 | 01 | CA | RAILROAD MEDICARE | OTHER | 300049623 | 01 | CA | RAILROAD MEDICARE | OTHER | 00A328752 | 01 | CA | MEDICARE PTAN | OTHER | 00A328753 | 01 | CA | MEDICARE PTAN | OTHER | 00A328750 | 05 | CA | MEDICAID |