Basic Information
| Provider Information | |||||||||
| NPI: | 1982656203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHONG | ||||||||
| FirstName: | WOOK-CHIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 3148 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926236217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492630473 | ||||||||
| Practice Location | |||||||||
| Address1: | 168 N BRENT ST | ||||||||
| Address2: | 402 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882340004 | ||||||||
| FaxNumber: | 8056413965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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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 | 2085R0202X | C50789 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00C507890 | 05 | CA | MEDICAID | 00C507890 | 01 | CA | BLUE SHIELD OF CA | OTHER |