Basic Information
Provider Information | |||||||||
NPI: | 1881012722 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHONG | ||||||||
FirstName: | JULIO | ||||||||
MiddleName: | TIAN-FA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 CROSSROADS DR STE 306 | ||||||||
Address2: |   | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211175437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4437382872 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 EXEMPLA CIR STE 250 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | CO | ||||||||
PostalCode: | 800263392 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7205363011 | ||||||||
FaxNumber: | 3034685117 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2014 | ||||||||
LastUpdateDate: | 10/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D0086257 | MD | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.