Provider Demographics
NPI:1174602403
Name:WANG, JUNG SHONG (MD)
Entity type:Individual
Prefix:
First Name:JUNG SHONG
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 SOUTH PRAIRIE AVENUE
Mailing Address - Street 2:UNIT 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605
Mailing Address - Country:US
Mailing Address - Phone:312-945-3018
Mailing Address - Fax:
Practice Address - Street 1:1940 EAST 87TH STREET
Practice Address - Street 2:SUITE 1 & 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-933-0600
Practice Address - Fax:773-933-0255
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
211134Medicare ID - Type Unspecified
D12769Medicare UPIN