Basic Information
| Provider Information | |||||||||
| NPI: | 1750764460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | HUDSON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8441 STATE HWY 47 | ||||||||
| Address2: | STE 3115 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794369703 | ||||||||
| FaxNumber: | 9794360072 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 E 29TH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778022622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797748200 | ||||||||
| FaxNumber: | 8776015854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 7666 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2B4320 | 01 | TX | MEDICARE | OTHER |