Basic Information
| Provider Information | |||||||||
| NPI: | 1639301641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | CHUNG MING | ||||||||
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| Credential: | M.B.,B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 NW 13TH ST | ||||||||
| Address2: | PMB 251 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326092835 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3450 HULL RD | ||||||||
| Address2: | BOX 112727 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326074144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/04/2017 | ||||||||
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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 | 207X00000X | ME118688 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | JA171Z | 01 | FL | MEDICARE PTAN | OTHER | 021309100 | 05 | FL | MEDICAID |