Basic Information
| Provider Information | |||||||||
| NPI: | 1841399615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOHN | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | HI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6301 S MCCLINTOCK DR | ||||||||
| Address2: | #101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802142300 | ||||||||
| FaxNumber: | 4802142301 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 S KYRENE RD | ||||||||
| Address2: | #1 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852264685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807858700 | ||||||||
| FaxNumber: | 4807858787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 30500 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00014245 | 01 | BANNER HEALTH PLAN | OTHER | 1Z65553 | 01 | HEALTHNET | OTHER | 713439 | 01 | AZ | AHCCCS | OTHER | 7134390 | 01 | DES | OTHER | 713439001 | 01 | APIPA | OTHER | AZ0719840 | 01 | BLUE CROSS BLUE SHIELD | OTHER |