Basic Information
| Provider Information | |||||||||
| NPI: | 1659357804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | WILLIS | ||||||||
| MiddleName: | CLEMENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | P3700 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 33420 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 64006 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | P00031103 | 01 | CO | RR MCRE RIA | OTHER | P00002241 | 01 | CO | RR MCRE MIC | OTHER | 1659357804 | 01 | WY | WY MEDICAID | OTHER | 01334200 | 05 | CO | MEDICAID |